AI辅助住院病历书写在县级妇幼保健机构的实践与成效OA

To explore the application path of AI-assisted inpatient medical record writing in county-level maternal and child health institutions,and to evaluate its effects on improving medical record quality,writing effi-ciency,and medical staff satisfaction.Methods A self-controlled before-and-after study was adopted.Ten prac-ticing physicians were randomly selected from Maternal and Child Health Hospital of Funan County as research subjects.The control group consisted of 200 medical records written manually in the traditional way from January to June 2024.The observation group included 200 medical records written with AI assistance from July to December 2024.Results The average quality score of medical records in the observation group was higher than that in the control group(95.56 points vs.89.23 points).The rate of Grade A medical records in the observation group was 77.0％,which was 26 percentage points higher than the 51.0％in the control group.Moreover,there were no Grade C medical records in the observation group(compared with 2 cases in the control group).The average time for medical record filing in the observation group was faster than that in the control group(3.56 d vs.5.87 d).The medical staff satisfaction rate in the observation group was significantly higher than that in the control group(100％vs.60％).Conclusions The adoption of AI-assisted writing for inpatient medical records can signifi-cantly improve the quality and writing efficiency of inpatient medical records in county-level maternal and child health institutions,and enhance medical staff satisfaction.