AI病案质控系统在医疗机构病案管理中的应用分析

Application Analysis of AI Medical Record Quality Control System in Medical Records Management

目的探究AI病案质控系统在医疗机构病案管理中的应用效果。方法选取2021年1月—2022年12月济南市章丘区人民医院病案室20名工作人员及AI病案质控系统实施前后各800份病案资料为研究对象。其中2021年1—12月实施传统纸质病案管理方式,记为实施前;2022年1—12月实施基于AI病案质控系统的管理方式,记为实施后。实施前后为同一批工作人员。对比实施前后病案资料错漏率,借阅、检索、复印时间及病案管理质量评分。结果AI病案质控系统实施后,病案资料错漏率低于实施前,病案资料借阅、检索、复印时间短于实施前,差异有统计学意义(P均<0.05)。实施后,病案管理质量评分高于实施前,差异有统计学意义(P均<0.05)。结论以信息化技术为基础的AI病案质控系统的实施,使医院的病案管理质量得到了很大的提升,在诊疗过程中,可以更快地进行患者病案数据的搜索和查询。同时,病案的电子存档行为,可以更好地确保病案资料中内容的准确性和清晰度,使其可以精确地反映患者的各种信息,从而帮助医生在临床医疗实施过程中,有针对性地调整治疗方案,更好地提高医院的医疗服务质量。

Objective To explore the application effect of AI medical record quality control system in medical records management.Methods A total of 20 staff members of the medical record room of Zhangqiu District People's Hospital of Jinan City from January 2021 to December 2022 and 800 medical records before and after the implementation of the AI medical record quality control system respectively were selected as the study objects.From January 2021 to December 2021,traditional paper medical record management was implemented,which was set as before implementation,from January 2022 to December 2022,the management based on the AI medical record quality control system was implemented,which was set as after implementation.The staff before and after implementation were same.Error and leakage rate and time for borrowing,retrieval,and photocopying of the medical records,and score of medical record management quality were compared before and after implementation.Results The error and leakage rate of medical records after implementation was lower than that before implementation,the borrowing time,retrieval time and copy time after implementation were shorter than those before implementation,the differences were statistically significant(all P<0.05).The score of medical record management quality after implementation were higher than that before implementation,the difference was statistically significant(all P<0.05).Conclusion The implementation of the AI medical record quality control system based on information technology greatly improved the quality of medical record management in hospitals,and the search and query of patient medical record data can be carried out faster in the process of diagnosis and treatment.Moreover,the electronic archiving of medical records can better ensure the accuracy and clarity of the contents of the medical records,so that the medical records can accurately reflect the information of patients,so as to adjust the treatment plan in the clinical treatment implementation process,and thus better improve the quality of medical services in hospitals.