基于新型CDSS辅助的病案首页填报及质控  

The first page filling and quality control of medical records based on new CDSS

作　　者：光奇[1] 王建林 赵正斌[2] 丁雪乾 GUANG Qi;WANG Jianlin;ZHAO Zhegnbin;DING Xueqian(Information Centre,Lanzhou University First Hospital,Lanzhou 730030,Gansu,China;Department of Medical Record,Lanzhou University First Hospital,Lanzhou 730030,Gansu,China)

机构地区：[1]兰州大学第一医院信息中心,甘肃兰州730030 [2]兰州大学第一医院病案科,甘肃兰州730030

出　　处：《中国现代医生》2023年第14期110-113,共4页China Modern Doctor

基　　金：甘肃省科技计划项目(20YF8FA080)。

摘　　要：基于人工智能技术的新型临床决策支持系统,可通过构建设计编码规则与知识库系统、优化质控逻辑与质控指标体系,对医疗过程进行智能监测和管控,实时监控病案首页的填写情况与质量,强化医疗过程质量稽查,对存在质量缺陷与不符质控规则的诊疗流程进行预警提醒,有助于实现更有效的病案管理与医疗质控。The new clinical decision support system based on artificial intelligence technology could design coding rules and knowledge base system,optimized quality control logic and quality control index system,intelligent monitoring and control of medical processes,real-time monitoring of the completion and quality of the first page of the medical case,strengthening the quality audit of the medical process,early warning and reminding of the treatment process with quality defects and non-compliance with quality control rules,helping to achieve more effective medical case management and medical quality control.

关 键 词：临床决策支持系统 人工智能 数据处理 病案首页 质控 

分 类 号：R197.324[医药卫生—卫生事业管理]