Abstract：Objective To solve the problems of low rate of traditional electronic medical record data and lagging quality control of medical
record, to propose a wisdom electronic medical record system. Methods Standardized medical terms were built based on the data element
model, the full-structured input and storage of electronic medical records was realized by calling standardized medical terms, the whole
process quality control of medical records was carried out through the quality control system based on rule engine. An intelligent evaluation
system was built to automatically evaluate medical records and diagnosis and treatment data, and support the retrieval and export of
medical records from any dimension. Results The knowledge base has accumulated more than 200000 standardized medical terms
and 760 million pieces of medical data, and medical data with medical significance accounted for 84%. The automatic generation rate
of medical record homepage has increased from 19.97% to 77.99%, the rate of grade A medical records has increased from 96.21%
to 99.01%, and the diagnosis related groups settlement rate has increased from 90.08% to 97.99%. In the process of COVID-19
prevention and control, there has been no missed diagnosis and 0 infection in the hospital. Conclusion The intelligent medical record
system effectively improves the utilization rate of medical record data, medical record quality and medical quality.
车滢霞a，严丽霞a，秦锡虎b，陈强a，张锋a，郑晓渊a. 智慧医疗背景下智慧病历系统的研究与应用[J]. 中国医疗设备, 2022, 37(12): 105-108.
CHE Yingxiaa, YAN Lixiaa, QIN Xihub, CHEN Qianga, ZHANG Fenga, ZHENG Xiaoyuana. Design and Application of Wisdom Electronic Medical Record System Under the
Background of Wise Medical. China Medical Devices, 2022, 37(12): 105-108.
