Efficacy analysis of human-machine coupling in quality control of inpatient medical records
10.3969/j.issn.1671-332X.2025.10.029
- VernacularTitle:人机耦合质控住院病历成效分析
- Author:
Lipeng CAO
1
;
Xiaoming XIE
1
;
Ye WU
1
Author Information
1. 南京医科大学附属无锡人民医院 江苏无锡 214000
- Publication Type:Journal Article
- Keywords:
Human-machine coupling rules;
Large language model;
Medical records;
Quality control
- From:
Modern Hospital
2025;25(10):1599-1601
- CountryChina
- Language:Chinese
-
Abstract:
Objective To analyze the results of human-machine coupling quality control(QC)for inpatient medical re-cords,compare them with manual QC results,and evaluate the value of the human-machine coupling approach.Methods Dis-charge medical records from a tertiary hospital between January 1,2024,and November 30,2024,underwent QC via two meth-ods:human-machine coupling QC and manual QC.Manual QC was performed based on medical record documentation standards and medical record management quality control indicators.The differences in the results obtained by human-machine coupling QC and manual QC were statistically analyzed.Results The human-machine coupling method reviewed 76 204 medical records,i-dentifying 204 544 issues.Manual QC reviewed 521 records,identifying 2 032 issues.The identified problems were categorized into five types:documentation,diagnosis and treatment,front page(administrative data),communication documents,and ap-proval documents.Conclusion Rule-based human-machine coupling QC achieves comprehensive and full-process coverage of inpatient medical records.The generated QC reports can display the distribution and correction status of detected issues,provi-ding a basis and direction for hospital management.
