现代医院2025，Vol.25Issue(10)：1599-1601,3.DOI:10.3969/j.issn.1671-332X.2025.10.029
人机耦合质控住院病历成效分析
Efficacy analysis of human-machine coupling in quality control of inpatient medical records
曹丽鹏 1谢晓明 1吴晔1
作者信息
- 1. 南京医科大学附属无锡人民医院 江苏无锡 214000
- 折叠
摘要
Abstract
Objective To analyze the results of human-machine coupling quality control(QC)for inpatient medical re-cords,compare them with manual QC results,and evaluate the value of the human-machine coupling approach.Methods Dis-charge medical records from a tertiary hospital between January 1,2024,and November 30,2024,underwent QC via two meth-ods:human-machine coupling QC and manual QC.Manual QC was performed based on medical record documentation standards and medical record management quality control indicators.The differences in the results obtained by human-machine coupling QC and manual QC were statistically analyzed.Results The human-machine coupling method reviewed 76 204 medical records,i-dentifying 204 544 issues.Manual QC reviewed 521 records,identifying 2 032 issues.The identified problems were categorized into five types:documentation,diagnosis and treatment,front page(administrative data),communication documents,and ap-proval documents.Conclusion Rule-based human-machine coupling QC achieves comprehensive and full-process coverage of inpatient medical records.The generated QC reports can display the distribution and correction status of detected issues,provi-ding a basis and direction for hospital management.关键词
人机耦合规则/大模型/病历/质控Key words
Human-machine coupling rules/Large language model/Medical records/Quality control分类
预防医学引用本文复制引用
曹丽鹏,谢晓明,吴晔..人机耦合质控住院病历成效分析[J].现代医院,2025,25(10):1599-1601,3.
