摘要
目的:构建产科电子病历质控平台,优化电子病历质控流程和方法。方法:以上海交通大学医学院附属国际和平妇幼保健院产科电子病历为研究对象,分析当前电子病历中存在的问题并基于电子病历质控平台设计质控流程。结果:电子病历的结构化取得了较好成效,在产时总结中命名实体识别精确率超过97%,电子病历质控流程从多方面实现病历全生命周期质控。结论:电子病历质控平台具有广阔的应用前景,可有效提高病案质控人员的工作效率,为临床医疗数据的质量管理提供帮助。
Objective To build an electronic medical records(EMR) quality control platform for obstetrics and explore the process and methods of EMR quality control.Methods Taking the obstetrics EMR in International Peace Maternal and Child Health Hospital Affiliated to Shanghai Jiaotong University School of Medicine as the research object,the problems in the current EMR quality control were analyzed and the quality control process was designed based on the EMR quality control platform.Results The EMR structuring have achieved good results,with an accuracy of more than 97% for named entity recognition in the delivery summary,and the EMR quality control process proposed in this paper realized the quality control from many aspects of the whole life cycle of EMR.Conclusion The EMR quality control platform has a broad application prospect,which can effectively improve the efficiency of EMR quality control personnel and facilitate quality management of clinical medical data.
作者
李梦翔
杨东见
陈磊
季新华
LI Mengxiang;YANG Dongjian;CHEN Lei;JI Xinhua(Information Department,International Peace Maternal and Child Health Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,Shanghai 200030,China;Administration Office,International Peace Maternal and Child Health Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,Shanghai 200030,China)
出处
《中国数字医学》
2024年第12期75-79,共5页
China Digital Medicine
基金
上海申康医院发展中心管理研究项目(2020SKMR-44)
上海市2022年度“科技创新行动计划”启明星培育(扬帆专项)(22YF1453200)。
关键词
电子病历质控
命名实体识别
人工智能
电子病历结构化
Electronic medical records quality control
Named entity recognition
Artificial intelligence
Electronic medical record structuring
