环节病历质量智能监测系统的研制与应用

Development and Application of Intelligent Monitoring System of Link Medical Records Quality

目的应用计算机技术实现医院环节病历质量的智能控制。方法以环节病历质量要求为基础建立质量监测指标体系,从业务系统中抽取数据,运用计算机系统以指标为单元对环节病历进行语义分析、关联分析等,从而自动产生环节病历质量指标监测数据,并以多种方式进行提示与预警。结果实现计算机自动分析病历质量、查找环节病历缺陷,并及时对病历质量指标或缺陷进行预警提示,建立计算机自动分析、查找病历质量控制规则的机制。结论应用计算机技术建立的环节病历质量智能控制系统对提高临床医疗质量、保障医疗安全、提高医院管理能力、降低管理成本等方面具有较好的作用。

Objective Applied computer technology to realize the intelligent control of quality of hospital link medical records.Methods Based on requirements of medical records quality established quality monitoring indicator system,and extracted data from business systems,then carried on analysis,like semantic analysis,correlation analysis and so on,on link medical records by the use of a computer system and indicators,so as to automatically generate monitoring data,and inform tips and warnings in many ways.Results Realized the computer automatic analysis of medical record quality,found the link of medical records and timely warning of the quality of medical records,and established rules of computer automatic analysis and medical records quality.Conclusion Applied computer technology to establish intelligent control system of link medical quality to improve the quality of clinical medical and medical security,to improve the ability of hospital management,and to reduce the management cost.