基于人工智能的中医门诊病历质控及探讨

Discussion on Quality Control of Traditional Chinese Medicine Outpatient Medical Records Based on Artificial Intelligence

中医门诊病历是记录患者病情和诊疗过程的重要资料,其质量直接关系到医疗安全、疗效评价及后续的科研工作。由于中医诊疗的个体化特点和病历书写者的水平差异,中医门诊病历常常存在信息缺失、描述不准确或不规范等问题,这些问题不仅影响临床治疗决策的准确性,也给后续的质量评估和科学研究带来困难。本文通过对浙江省中医院门诊病历质控系统分析,探讨中医门诊病历的质量控制,从而提升中医门诊病历质量。

Traditional Chinese medicine(TCM)outpatient medical records are important information for recording the patient's condition and the diagnosis and treatment process,and their quality is directly related to medical safety,evaluation of therapeutic efficacy and subsequent scientific research work.Due to the individualized characteristics of TCM diagnosis and treatment and differences in the level of medical record writers,TCM outpatient medical records often have problems such as missing information,inaccurate descriptions,or irregularities,which not only affect the accuracy of clinical treatment decisions,but also bring difficulties in subsequent quality assessment and scientific research.This paper discusses the quality control of TCM outpatient medical records by analyzing the quality control system of outpatient medical records in Zhejiang Provincial Hospital of Chinese Medicine,so as to improve the quality of TCM outpatient medical records.