现代医院2026，Vol.26Issue(6)：942-945,4.DOI:10.3969/j.issn.1671-332X.2026.06.015
基于人工智能的病历质控系统构建与应用效果评估
Construction and application effect evaluation of artificial intelligence-based medical record quality control system
摘要
Abstract
Objective To analyze the impact of the application of the artificial intelligence(AI)medical record quality control system on medical record quality,provide a reference for further research on the application of AI in medical record man-agement,and facilitate high-quality medical record management.Methods A Grade A tertiary general hospital in Guangzhou constructed an AI medical record quality control system by integrating technologies such as natural language processing and ma-chine learning with the hospital's EMR,HIS,PACS,LIS and other systems,based on a knowledge rule base,a logical relation-ship base and a logical condition base.The system was officially launched on July 1,2024.A total of 15 422 medical records of discharged patients from April 1 to June 30 2024 were selected as the control group,and 15 508 medical records of discharged pa-tients from July 1 to September 30,2024 were selected as the study group.The connotation defect rate,defect types and medical record quality scores of the two groups were compared.The quality control of inpatient medical records was conducted in accord-ance with the relevant regulations and evaluation standards issued by the National Health Commission and the Health Commission of Guangdong Province.The writing quality was evaluated covering the medical record home page,admission records,progress notes,operation records and other documents,with a full score of 100 points for each medical record.Results After the launch of the AI medical record quality control system,the medical record connotation defect rate decreased from 57.77％to 43.64％(x2=617.875,P＜0.001),and the medical record quality score increased from(98.34±3.03)to(99.02±2.09)(t=-22.986,P＜0.001).Among them,the frequency of connotation defects in the medical record home page(x2=182.599,P＜0.001),daily progress notes(x2=162.914,P＜0.001),admission records(x2=41.916,P＜0.001),and discharge(death)records(x2=99.568,P＜0.001)decreased significantly.Conclusion The AI medical record quality control system helps reduce medical record connotation defects,improve medical record quality,and facilitate efficient medical record manage-ment.关键词
人工智能病历质控系统/病案质量/内涵质控/内涵缺陷项目Key words
Artificial intelligence medical record quality control system/Medical record quality/Connotation quality control/Connotation defect items分类
医药卫生引用本文复制引用
谭华珍,邓活清,陈久华,叶润生,张文伟..基于人工智能的病历质控系统构建与应用效果评估[J].现代医院,2026,26(6):942-945,4.基金项目
广州市卫生健康科技一般引导项目(20251A011113) （20251A011113）
广州市花都区医疗卫生一般科研专项项目(25-HDWS-020) （25-HDWS-020）
