某三甲医院基于AI的病历质量管理系统应用  

Application of AI-based Medical Record Quality Management System in a 3A Hospital

作　　者：毛丽[1] 张文一[1] 马德好 王博[1] 张博雅 张璇[1] Mao Li;Zhang Wenyi;Ma Dehao;Wang Bo;Zhang Boya;Zhang Xuan(Chinese People's Liberation Army General Hospital Institute of Management,Beijing,100853;不详)

机构地区：[1]中国人民解放军总医院医院管理研究所,北京市100853

出　　处：《中国病案》2022年第11期26-29,共4页Chinese Medical Record

摘　　要：电子病历系统是医院信息化建设的核心要素,是医疗纠纷的主要依据,是医疗机构绩效考核的关键指标,某三甲医院借助AI技术,研发病历质量管理系统,构建病历质量闭环管理体系,通过病历质量监测、预警、评审、改进、分析等功能,对环节病历形式质量和内涵质量进行智能管控,在全院范围内,实现环节病历质量同质化、同标准、智能化的质量监测评价管理,持续改进病历质量。通过该系统应用,完成了医院异构数据有效整合和标准化治理,实现了智能判断病历缺失、缺陷、逻辑性问题,按事件高效处理病历时效性、内涵性问题,全面高效地辅助医院管理层和临床医务人员完成病历质控工作,确保医院环节病历质量同质化提升,助力医疗质控高质量发展。Electronic medical record system is the core element of hospital information construction,the main basis of medical disputes,and the key index of performance evaluation of medical institutions.With the help of AI technology,a 3A hospital developed a medical record quality management system and constructed a closed-loop medical record quality management system.Through the functions of medical record quality monitoring,early warning,review,improvement,and analysis,this system can intelligently manage and control the form quality and connotation quality of link medical records,realize the homogeneity,the same standard,and intelligent quality monitoring and evaluation management of medical records in the whole hospital,and continuously improve the quality of medical records.Through the application of this system,the effective integration and standardized management of heterogeneous data in hospitals have been completed.This system realizes intelligent judgment on the lack,defect,and logical problems of medical records,and efficiently handles the timeliness and connotation problems of medical records according to events.It comprehensively and efficiently assists the hospital management and clinical medical staff to complete the quality control of medical records,ensures the homogeneous improvement of the quality of medical records in the hospital,and facilitates the high-quality development of medical quality control.

关 键 词：病历质量 管理系统 AI 

分 类 号：R197.323[医药卫生—卫生事业管理]