Intelligent case quality control method and system

A quality control method and case technology, applied in the field of clinical medical management, can solve problems such as poor scalability, low flexibility, and time-consuming, and achieve the effects of high degree of personalization, improved quality control efficiency, and improved filling quality

Active Publication Date: 2021-11-26
ZHONGDA HOSPITAL SOUTHEAST UNIV
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  • Summary
  • Abstract
  • Description
  • Claims
  • Application Information

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 l...

Method used

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  • Intelligent case quality control method and system
  • Intelligent case quality control method and system
  • Intelligent case quality control method and system

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Experimental program
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Effect test

Embodiment 1

[0031] The intelligent case quality control system mainly adds the automatic quality control screening process of the system. When all medical records are submitted according to the process and transferred to the corresponding quality control inspection link, the quality control doctor clicks on the quality control score, and the engine can automatically calculate the corresponding medical record quality control scoring standard. Complete medical record rule verification according to the rules: obtain all defect numbers at the same time, and automatically calculate according to the corresponding defect deduction standard, and obtain the medical record score result to the quality control personnel in the corresponding link.

[0032] Preferable: Manual quality inspection steps are also set up. After entering the system, quality inspectors do not need to check the entire document to screen for defects from the beginning to the end, but only need to review and verify the defect resu...

Embodiment 2

[0066]Example 2: Taking a hospital as an example, before adopting the above intelligent case quality control method, only 4 quality control specialists were set up, and the average number of quality control personnel per day was 5-8 medical records per person, and the average daily discharge rate was 225 The number of medical records generated per month is about 6,500. Based on 20 working days per month, the number of medical records that can actually be controlled with high quality per month is at most 640, accounting for less than 10%, which is quite different from the demand. After adopting the association relationship that only sets the path length to 1, the actual test can actually achieve a maximum of 5,000 medical records with high-quality quality control per month. The speed has been improved; the subsequent manual quality inspection steps take up more time; after increasing the length of the associated path and the number of training samples, the quality inspection spe...

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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...

Claims

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Application Information

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IPC IPC(8): G16H10/60G16H40/20G06F16/36
CPCG16H10/60G16H40/20G06F16/367
Inventor 史亚香丁佳丽
Owner ZHONGDA HOSPITAL SOUTHEAST UNIV
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