通讯作者: 刘莉莉, liullth@126.com

DOI：10.12201/bmr.202605.00088

Construction and Practice of Connotation Quality Control System of Traditional Chinese Medicine Electronic Medical Record Based on Artificial Intelligence Large Model

• 摘要：目的/意义 针对传统中医电子病历质控存在的效率低下、评判标准不一、难以覆盖内涵逻辑等问题，探索并实践结合人工智能大模型的中医电子病历内涵质控新模式，提升质控工作的智能化、自动化与精细化水平。方法/过程 在某三级甲等中医医院部署与实施，采用“通用大模型+病历质控专精训练”技术模式，综合运用规则引擎与智能模型融合判定、智能语义分析与上下文推理、检索增强生成等核心技术。结果/结论 系统上线运行后，实现了中医电子病历内涵质量的实时自动核查，其中病历完整性合格率升至 94%，四诊记录、辨证分型、方药配伍的逻辑矛盾显著减少，文字错别字、中药剂量异常等问题得到有效自动排查，病历准确性与书写规范性得到明显提升。该系统有效强化了对医疗过程合规性、诊疗逻辑合理性的深度把控，为持续改进中医病历质量、保障临床医疗安全、提升医院精细化管理水平提供了有力的技术支撑。

  关键词： 人工智能; 大模型; 中医电子病历; 内涵质控; 医疗质量

   

  Abstract: Purpose/Significance In view of the problems of low efficiency, different evaluation criteria and difficulty in covering the connotation logic in the quality control of traditional Chinese medicine electronic medical records, a new mode of connotation quality control of traditional Chinese medicine electronic medical records combined with artificial intelligence model is explored and practiced to improve the intelligence, automation and refinement level of quality control work. Method/Process The system was deployed and implemented in a tertiary hospital of traditional Chinese medicine. The technical mode of general large model + medical record quality control professional training was adopted, and the core technologies such as rule engine and intelligent model fusion judgment, intelligent semantic analysis and context reasoning, retrieval enhancement generation were comprehensively used. Result/Conclusion After the on-line operation of the system, the real-time automatic verification of the connotation quality of electronic medical records of traditional Chinese medicine was realized, in which the qualified rate of medical record integrity rose to 94 %, the logical contradictions of four diagnostic records, syndrome differentiation and prescription compatibility were significantly reduced, and the problems such as wrong characters and abnormal dosage of traditional Chinese medicine were effectively and automatically investigated, and the accuracy and writing standardization of medical records were significantly improved. The system effectively strengthens the deep control of the compliance of the medical process and the rationality of the diagnosis and treatment logic, and provides a strong technical support for the continuous improvement of the quality of TCM medical records, the guarantee of clinical medical safety and the improvement of the fine management level of the hospital.

  Key words: artificial intelligence,large-sized model,electronic medical record of traditional chinese medicine,connotation quality control,medical quality; ; ; ; 

  提交时间：2026-05-25

  版权声明：作者本人独立拥有该论文的版权，预印本系统仅拥有论文的永久保存权利。任何人未经允许不得重复使用。
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• 序号	提交日期	编号	操作
  1	2026-03-26	10.12201/bmr.202605.00088V1	下载

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