基于AI技术的电子病历质控系统构建与实践

Construction and Practice of Electronic Medical Records Quality Control System Based on AI Technology

构建基于AI技术为核心的电子病历质控系统。应用计算机自然语言处理技术对电子病历内容进行结构化解析,通过医院病历缺陷规则知识库及临床真实脱敏病历标注后进行机器学习,建立以机器质检+人工复核方式的电子病历质控系统,实现了医院电子病历智能质控全覆盖,质控结果准确率达到93.6%,有效减少了高年资医生用于病历质控的时间,提升了临床病历质量。

The quality control system of electronic medical records based on AI technology was constructed.The content of electronic medical records is analyzed structurally by using natural language processing technology.The quality control system of electronic medical records based on machine quality inspection and manual review is established by machine learning about the defect rule knowledge base of hospital medical records and marking of real medical records desensitized.The intelligent quality control system of hospital electronic medical record was fully covered,and the accuracy of quality control results reached 93.6%.It effectively reduced the time of senior doctors for medical records quality control,and improved the quality of clinical medical records.