关键词: 住院医师培训, 　人工智能, 　临床决策支持系统, 　电子病历

Abstract: According to the quality control index of disease and disease management issued by the National Health Commission, the basic standard of medical record writing, and the quality specification of data filling in the front page of inpatient medical record, a hospital formulates quality control rules. The  clinical decision support system (CDSS) system based on artificial intelligence was established by natural language processing technology, and was seamlessly connected to the electronic medical record system. When residents write electronic medical records, the system makes real-time judgment of writing content, finds out the diagnosis and treatment defects in time, and forms a message pop-up reminder to correct the errors in the medical records, improves the medical record writing, and ensures the quality of filling in the front page of medical records. After using the system, the achievement rate of quality control indicators was significantly improved, and the defect rate of medical records was significantly decreased, which effectively improved the standardization of disease diagnosis and treatment and medical record writing of residents.

Key words: resident training,  artificial intelligence, clinical decision support system, electronic medical records