AI病历内涵质控系统的建设与应用

Construction and Application of AI Medical Records Connotation Quality Control System

目的 通过实时监测院内医疗行为,实现对病历内涵质量的全过程、系统化和智能化管理,提升病案质量管理工作的科学化、精细化水平。方法 通过整合医院内多个业务系统中的多源异构数据,运用自然语言处理、机器学习等人工智能技术对文本数据进行结构化处理,并建立完善的质控规则体系和病历质量评分体系,对医疗行为进行实时监测和评估,全面追踪病历内涵质量。结果 实现了病历内涵质控的闭环管理,健全了“事前提醒、事中监管、事后质控”的质控管理体系,有效提升了病历内涵质量。结论 AI病历内涵质控系统的建设,实现了从数据到管理再到临床的闭环,为医院临床业务的高质量发展提供了数据支撑和保障。

Objective Through real-time monitoring of hospital medical behavior,the whole process,systematic and intelligent management of the connotation quality of medical records can be realized,and the scientific and refined level of medical records quality management can be improved.Methods By integrating multi-source heterogeneous data in multiple business systems of hospitals,artificial intelligence technologies such as natural language processing and machine learning are used for structured data processing,and a sound quality control rule system and medical records quality scoring system are established to monitor and evaluate medical behavior in real time and comprehensively track medical records quality.Results The closed-loop management from“system automatically sends quality control message-clinical rectification-expert re-quality control”has been realized,and the quality control management system of“advance reminder”,“supervision”and“post-event quality control”has been truly achieved,effectively improving the quality of medical records.Conclusion The construction of the AI medical records in-depth quality control system has achieved a closed-loop of medical records in-depth quality control from data to management to clinical practice,providing data support and assurance for the high-quality development of hospital clinical services.