Intelligent case quality control method and system

Abstract

According to the invention, an artificial intelligence technology is taken as a core, and through understanding of medical record semantics, evaluation of diagnosis and treatment paths, searching of defect contents and reason recognition, research and judgment from content integrity, timeliness and the like can be realized, and content quality control on medical record documents from term normalization, data consistency, logic consistency, diagnosis sufficiency, drug interaction and the like can also be realized. Through the basic quality, the link quality and the end quality of the electronic medical record and management, the quality control department not only can timely find and correct errors in the medical record and reduce and avoid medical accidents, errors and disputes, but also can truly reflect the condition of disease diagnosis and treatment of each department.

Description

【Technical field】 [0001] The invention belongs to the technical field of clinical medical management, in particular to an intelligent case quality control method and system. 【Background technique】 [0002] Quality is the eternal theme of hospital management, and the survival and development of hospitals are closely related to the quality of management. In medical quality management, the management and control of medical record quality is an important part of it. Medical records are files that record the occurrence, development, diagnosis, and treatment of a patient's disease. They are detailed records of medical activities such as admission, examination, diagnosis, and treatment by medical personnel. They are key indicators for hospital assessment and powerful evidence for resolving medical disputes. It is also the main material of clinical research. The objectivity, completeness, and accuracy of medical records reflect the quality of medical staff's diagnosis and treatmen...

AI Technical Summary

Problems solved by technology

[0003] In order to supervise and manage the irregular writing behavior of doctors, the construction of quality control management functions has become more and more important. The common document quality control functions are mostly based on post-event quality control, and cannot be controlled during the hospital, such as admission records. Timeliness, timeliness of superior physician rounds, etc. cannot be controlled in real time, and irregular medical record writing behaviors in clinical practice cannot be detected in a timely and effective manner

The current form of quality control mostly relies on the mandatory control of the information system, focusing on the quality control of the time limit and completeness of medical records. Therefore, the scalability is poor and the flexibility is low, which makes it difficult for the management department to maintain the new information conveniently and quickly. In addition, this type of quality control system cannot achieve effective results for the connotation quality control of medical records, such as whether the chief complaint can lead to the first diagnosis, whether there is any contradiction between the current medical history and the first course record, and whether the ward round record reflects Medical history, etc. still rely on manual inspection by quality controllers, which makes quality control work take a lot of time and effort

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