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《广州医药》编辑部

广州医药杂志服务号
医院管理

智能病案质控系统对病案质量和质控效率的影响

The influence of intelligent medical record quality control system on medical record quality and quality control efficiency

:633-638
 
      目的 探讨智能病案质控系统对病案质量及质控效率的影响,为优化病案管理模式提供依据。方法 选取2024年4月—9月传统人工质控病案2 000份(对照组)与2024年10月—2025年6月智能病案质控系统辅助质控病案2 000份(研究组),对比两组缺陷检出率、编码准确率、内涵质量达标率等病案指标,以及人均日均处理量、质控耗时、漏检率等效率指标。结果 研究组缺陷检出率(15.20%)高于对照组(8.30%);编码准确率(95.70%)、内涵质量达标率(93.50%)高于对照组(86.50%、82.30%)(均P<0.05);研究组人均日均处理量较对照组提升;单份病案质控耗时(4.80 min)缩短;漏检率(3.00%)降低62.50%(均P<0.05)。结论 智能病案质控系统可提升病案质量与质控效率,优化医疗资源配置,为DRG/DIP支付改革提供支持。

      Objective To explore the influence of intelligent medical record quality control system on medical record quality and quality control efficiency,so as to provide a basis for optimizing medical record management mode.Methods A total of 2 000 traditional manual quality control medical records(control group)from April to September 2024 and 2 000 intelligent medical record quality control system-assisted cases(experimental group)from October 2024 to June 2025 were selected.The study compared key indicators including defect detection rates,coding accuracy,and connotation quality compliance rates,along with efficiency metrics such as daily per capita processing volume,quality control time consumption,and missed detection rate between the two groups.Results The experimental group showed a significantly higher defect detection rate(15.20%)compared to the control group(8.30%).The coding accuracy(95.70%)and connotation quality compliance rate(93.50%)were notably higher than the those of control group(86.50% and 82.30%,P<0.05).The experimental group demonstrated improved daily processing capacity per capita,with a significant reduction in quality control time for individual medical records(4.80 minutes)and a 62.50% decrease in missed detection rate(3.00%,P<0.05).Conclusions Intelligent medical record quality control system can significantly improve the quality and quality control efficiency of medical records,optimize the allocation of medical resources,and provide support for DRG/DIP payment reform.

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