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DeepSeek在电子病历质控中的应用与分析OA

Application and Analysis of DeepSeek in Electronic Medical Record Quality Control

中文摘要英文摘要

电子病历在现代医疗中至关重要,然而现有的电子病历质控方法,包括传统人工质控和自动化质控系统,存在工作量大、效率低、质量控制覆盖不全面等问题,难以满足现代医疗环境下的高效质控需求.为此,本文提出一种基于DeepSeek大模型的电子病历质控系统,结合提示学习和基于知识库的检索增强生成技术,通过整合多源医学知识实现自动化质控.实验结果表明,该系统显著改善了病历漏填率、内涵缺陷率和病历质控率,病历漏填率从 9.42%降至 3.55%,内涵缺陷率由 76.52%降至 34.28%,病历质控率达到 100%.本文展示了基于DeepSeek技术的自动化质控方法在提升病历质量和工作效率方面的巨大潜力,并为未来病历质控的智能化发展提供了有力支持.

Electronic medical records(EMR)play a critical role in modern healthcare.However,existing methods for quality control of electronic medical records,including traditional manual quality control and automated quality control systems,suffer from issues such as high workload,low efficiency,and limited coverage,making them inadequate for meeting the demands of efficient quality control in contemporary healthcare environments.To address these challenges,this paper proposes an EMR quality control system based on the DeepSeek large model,integrating prompt learning and knowledge-base-based retrieval-augmented generation(RAG)techniques to achieve automated quality control by leveraging multi-source medical knowledge.The experimental results demonstrate that this system has significantly optimized the omission rate,content deficiency rate,and quality control effectiveness of medical records.The missing filling rate of medical records has dropped from 9.42%to 3.55%,the connotative defect rate has decreased from 76.52%to 34.28%,and the medical record quality control rate has reached 100%.This study demonstrates the great potential of the DeepSeek-based automated quality control approach in enhancing both EMR quality and operational efficiency,providing strong support for the future intelligent development of EMR quality control.

陶博;周帆帆;刘大锦;马秀

昆明医科大学第一附属医院 昆明 650032昆明医科大学第一附属医院 昆明 650032昆明医科大学第一附属医院 昆明 650032昆明医科大学第一附属医院 昆明 650032

信息技术与安全科学

病历质控人工智能DeepSeek提示学习检索增强生成

medical record quality controlartificial intelligenceDeepSeekprompt learningretrieval-augmented generation

《集成技术》 2026 (2)

104-115,12

10.12146/j.issn.2095-3135.20250516001

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