人工智能与人工复核结合在病案质控中的应用与效果评估  

Application and Effectiveness Evaluation of Combining Artificial Intelligence and Manual Review in Quality Control of Medical Cases

作　　者：王静[1] WANG Jing(Department of Medical Record Management,The First Affiliated Hospital of Shihezi University,Shihezi,Xinjiang,832000,China)

机构地区：[1]石河子大学第一附属医院病案管理科,新疆石河子832000

出　　处：《新疆医学》2025年第3期317-320,共4页Xinjiang Medical Journal

摘　　要：目的研究提出了一种创新的“人工智能+人工复核”质控模式,并系统评估其在新疆某三甲医院住院病案管理中的应用效果。旨在弥补现有质控方法的不足,为未来病案质控系统的优化提供参考。方法随机选择10个临床科室,选取2024年1月1日-5月31日采用“人工智能+人工复核”模式质控的12329份病案作为研究组,2023年8月1日-12月31日采用传统人工质控的11685份病案作为对照组。比较两组病案首页漏填率、内涵缺陷率、病案质量得分及质控效率。结果研究组首页漏填率(2.34%)和内涵缺陷率(20.54%)低于对照组(4.49%;55.00%),差异具有统计学意义(P<0.05);病案质量得分(91.85分)显著高于对照组(87.90分),同等人力的质控时间减少2个月。结论该创新质控模式显著提升了病案质量和质控效率,证明了其在实际应用中的显著优势。Objective This study proposes an innovative‘artificial intelligence+manual review’quality control model and systematically evaluates its application in the management of inpatient cases in a tertiary hospital in the Xinjiang.This model is designed to make up for the shortcomings of the existing quality control methods and to provide a reference for the optimisation of the future case quality control system.Methods 10 clinical departments were randomly selected,and 12329 cases with‘artificial intelligence+manual review’mode of quality control from 1 January to 31 May 2024 were chosen as the study group,while 11685 cases with traditional manual quality control from 1 August to 31 December 2023 were chosen as the control group.The two groups were compared in terms of first page omission rate,internal defect rate,case quality score and QC efficiency.Results The first page omission rate(2.34%)and the rate of internal defects(20.54%)of the study group were significantly lower than those of the control group(4.49%;55.00%),and the differences were statistically significant(P<0.05);the quality score of the cases(91.85)was significantly higher than that of the control group(87.90),and the QC time for the same manpower was reduced by 2 months.Conclusion This innovative QC model significantly improved case quality and QC efficiency,proving its significant advantages in practical application.

关 键 词：人工智能 病案质控模式 病案质量 内涵质控 

分 类 号：R197.3[医药卫生—卫生事业管理]