AI技术助力电子病历质量控制的应用  

Application and exploration of ai technology to assist quality control of electronic medical records

作　　者：季爽华 李全欢[1] 郑海娣[1] JI Shuanghua;LI Quanhuan;ZHENG Haidi(The First Affiliated Hospital of Zhejiang University School of Medicine,Hangzhou 310000,China)

机构地区：[1]浙江大学医学院附属第一医院,浙江杭州310000

出　　处：《现代医院》2024年第9期1442-1445,共4页Modern Hospitals

摘　　要：目的借助AI技术实现对全量病历的环节质控,进一步规范病历书写流程,解决人工质控模式流程滞后、不能覆盖全量病历等弊端。方法在无纸化电子病历系统的基础上构建了基于AI技术的电子病历质控系统,通过运行质控规则实现对全量电子病历的自动监控、提醒及反馈功能。结果AI质控系统实现了对100%电子病历的实时质控,病历书写的时效性、完整性得到显著提升。结论通过基于AI技术的病历质控系统可有效提升医院病历质控效率,显著提高电子病历书写质量,解决了人工质控的弊端。Objective To utilize AI technology to achieve quality control of all medical records,further standardize the medical record writing process,and address the shortcomings of the manual quality control model,such as the inability to cover all medical records.Methods Based on the paperless electronic medical record system,an electronic medical record quality control system based on AI technology was constructed.The system achieves automatic monitoring,reminders,and feedback functions for all electronic medical records by running quality control rules.Results The AI quality control system has achieved real-time quality control of 100%of electronic medical records,significantly improving the timeliness and completeness of medical record writing.Conclusion The medical record quality control system based on AI technology can effectively enhance the efficiency of hospital medical record quality control,significantly improve the quality of electronic medical record writing,and solve the shortcomings of manual quality control.

关 键 词：人工智能 电子病历 病历质控 

分 类 号：R197.324[医药卫生—卫生事业管理] R1197.323.1[医药卫生—公共卫生与预防医学]