光奇 王建林 赵正斌 丁雪乾

    [摘要]?基于人工智能技术的新型临床决策支持系统，可通过构建设计编码规则与知识库系统、优化质控逻辑与质控指标体系，对医疗过程进行智能监测和管控，实时监控病案首页的填写情况与质量，强化医疗过程质量稽查，对存在质量缺陷与不符质控规则的诊疗流程进行预警提醒，有助于实现更有效的病案管理与医疗质控。

    [关键词]?临床决策支持系统；人工智能；数据处理；病案首页；质控

    [中图分类号]?R197.324?[文献标识码]?A?[DOI]?10.3969/j.issn.1673-9701.2023.14.025

    The?first?page?filling?and?quality?control?of?medical?records?based?on?new?CDSS

    GUANG?Qi1，?WANG?Jianlin1，?ZHAO?Zhegnbin2，?DING?Xueqian1

    1.Information?Centre，?Lanzhou?University?First?Hospital，?Lanzhou?730030，?Gansu，?China;?2.Department?of?Medical?Record，?Lanzhou?University?First?Hospital，?Lanzhou?730030，?Gansu，?China

    [Abstract]?The?new?clinical?decision?support?system?based?on?artificial?intelligence?technology?could?design?coding?rules?and?knowledge?base?system，?optimized?quality?control?logic?and?quality?control?index?system，?intelligent?monitoring?and?control?of?medical?processes，?real-time?monitoring?of?the?completion?and?quality?of?the?first?page?of?the?medical?case，?strengthening?the?quality?audit?of?the?medical?process，?early?warning?and?reminding?of?the?treatment?process?with?quality?defects?and?non-compliance?with?quality?control?rules ......