人工智能辅助的互联网诊疗病历书写系统的建立及应用  

Establishment and application of AI-assisted medical record writing system based on mobile device

作　　者：廖文敏 石文娟 施楠 何仲廉[1] 李超峰[1] Liao Wenmin;Shi Wenjuan;Shi Nan;He Zhonglian;Li Chaofeng(Information Center,Cancer Institute,Sun Yat-sen University Cancer Center,Guangzhou 510080,China;Outpatient Office,Cancer Institute,Sun Yat-sen University Cancer Center,Guangzhou 510080,China)

机构地区：[1]中山大学肿瘤防治中心信息中心,广州510080 [2]中山大学肿瘤防治中心门诊办公室,广州510080

出　　处：《数字医学与健康》2025年第1期49-53,共5页DIGITAL MEDICINE AND HEALTH

摘　　要：目的:开发一款人工智能辅助的病历书写系统,以帮助医生更及时、高效地撰写互联网诊疗病历。方法:通过中山大学肿瘤防治中心掌上医院APP,集成如智能预问诊自动病史采集、报告文本光学字符识别、结构化病历文书自动输出、检验检查异常值自动识别插入、历史病历导入和电子签名等多项辅助功能。结果:显著提升了医生病历书写的便捷性和规范性。上线4个月内,该系统已支持医生撰写超过1万份互联网诊疗病历,且使用量逐月增长。结论:这一系统有效提升了病历书写效率,进而改善了互联网诊疗的整体质量、安全性及患者满意度。ObjectiveTo develop an AI-assisted medical record writing system to assist doctors in writing Internet-based medical records timely and efficiently.MethodsThe system was realized in the Sun Yat-sen University Cancer Center Hospital APP by integrating multiple auxiliary functions such as intelligent pre-diagnosis for automatic medical history collection,optical character recognition of report texts,automatic output of structured medical records,automatic identification and insertion of abnormal values in inspections,import of historical medical records,and electronic signatures.ResultsThe system significantly enhanced the convenience and standardization of doctors′medical record writing.Within four months of its launch,the system had supported doctors in writing over 10000 Internet-based medical records,with usage increasing month by month.ConclusionsThe system can effectively improve the efficiency of medical record writing,thereby enhancing the overall quality,safety,and patient satisfaction of Internet-based medical care.

关 键 词：互联网诊疗 病历书写 移动设备 人工智能 

分 类 号：R197.32[医药卫生—卫生事业管理]