医学信息2025，Vol.38Issue(14)：51-56,6.DOI:10.3969/j.issn.1006-1959.2025.14.008
基于AI技术的病案质控系统在病案管理中的应用研究
Research on the Application of AI Based on the Medical Record Quality Control System in Medical Record Management
摘要
Abstract
The application of medical record quality control system based on artificial intelligence(AI)technology for electronic medical record quality control can continuously improve the quality of medical record data and help the efficient management of hospital medical record data.This paper takes the introduction of a medical record quality control system based on AI technology in a tertiary general hospital for electronic medical record quality control,and establishes a medical record management control index system as an example,and selects the medical record management control index data of the hospital AI medical record system from July 2023 to June 2024 for collation,statistics and analysis.The results showed that after 1 year of continuous quality control management of medical record management control indicators,the rate of first-class medical records,the coincidence rate of antibacterial drug use records,and the integrity rate of physician rounds records were all improved.The incidence of unreasonable case replication decreased from 87.06％to 32.38％,and the incidence of surgical complications decreased from 2.78％to 0.43％.The medical record quality control system based on artificial intelligence can carry out rapid and efficient comprehensive quality control of electronic medical records,and can quickly obtain the data of medical record management control indicators for accurate analysis,improve the quality of medical records and work efficiency,and the effect of continuous improvement of medical record management indicators is obvious.关键词
AI技术/病历质控/病案管理Key words
AI technology/Medical record quality control/Medical records management分类
医药卫生引用本文复制引用
黎芳铃,周波,黄和邦,杨小花..基于AI技术的病案质控系统在病案管理中的应用研究[J].医学信息,2025,38(14):51-56,6.基金项目
广西壮族自治区卫生健康委员会自筹经费科研课题(编号:Z-B20221519) （编号:Z-B20221519）
