健康发展与政策研究2026，Vol.29Issue(1)：12-17,6.DOI:10.12458/HDPR.202504043
人工智能在病案管理中的应用现状及展望
Current status and prospects of artificial intelligence in medical record management
摘要
Abstract
Against the backdrop of escalating medical complexity and soaring patient volumes,traditional medical record management systems face significant challenges,including the intensified burden of clinical documentation,inefficiencies in quality control,and the underutilization of data value.By synthesizing global practices,this paper systematically analyzes the application value and inherent challenges of artificial intelligence(AI)across critical phases of medical record management.Core scenarios had been examined including AI-assisted documentation,intelligent quality control,the automated management of medical record face sheets,the construction of quality indicator systems,and unlocking the potential of medical record data.The integration of AI remarkably improves the quality and efficiency of medical record management,assists in establishing intelligent risk prevention systems,and advances data governance and real-world evidence(RWE)research.However,the widespread adoption of AI is still constrained by multidimensional hurdles,such as technical limitations,privacy concerns,and regulatory compliance risks.To facilitate a sustainable AI transition,this paper proposes a tiered governance framework.At the macro-level,an ecosystem integrating policies,regulations,and collaborative innovation must be established.At the meso-level,hospitals should drive institutional innovation through digital value transformation and technical integration.At the micro-level,operational workflows must be standardized,with an emphasis on physicians'ultimate accountability as final signatories and the enhancement of competency-based training.关键词
人工智能/病案管理/应用展望/医疗数据/分层治理Key words
artificial intelligence/medical record management/future prospects/medical data/tiered governance分类
医药卫生引用本文复制引用
姜若,陈亦飞,罗莉,帅海平,沈洁,谭申生,胡承方,狄建忠..人工智能在病案管理中的应用现状及展望[J].健康发展与政策研究,2026,29(1):12-17,6.基金项目
新一代人工智能国家科技重大专项(2021ZD0113504) （2021ZD0113504）
上海申康医院发展中心市级医院诊疗技术推广及优化管理项目(SHDC12024629) （SHDC12024629）
