Abstract
A nursing care planning system that automatically generated nursing summaries from information entered into the Psychiatric Outcome Management System (PSYCHOMS?, Tanioka et al.), was developed to enrich the content of nursing summaries at psychiatric hospitals, thereby reducing the workload of nurses. Preparing nursing summaries entails finding the required information in nursing records that span a long period of time and then concisely summarizing this information. This time consuming process depends on the clinical experience and writing ability of the nurse. The system described here automatically generates the text data needed for nursing summaries using an algorithm that synthesizes patient information recorded in electronic charts, the Nursing Care Plan information or the data entered for North American Nursing Diagnosis Association (NANDA) 13 domains with predetermined fixed phrases. Advantages of this system are that it enables nursing summaries to be generated automatically in real time, simplifies the process, and permits the standardization of useful nursing summaries that reflect the course of the nursing care provided and its evaluation. Use of this system to automatically generate nursing summaries will allow more nursing time to be devoted to patient care. The system is also useful because it enables nursing summaries that contain the required information to be generated regardless of who prepares them.
Highlights
A nursing summary provides a synopsis of the course of the patient’s hospitalization for a certain period of time and the received nursing care [1]
In preparing a nursing summary, the nurse must enter or record the required information on the designated form from the beginning, and at discharge, they must find the required events in a nursing record that spans a long period of time and concisely summarize the information
The aim of this study was to construct a system that automatically generates nursing summaries using data entered into the PSYCHOMS® nursing care planning system
Summary
A nursing summary provides a synopsis of the course of the patient’s hospitalization for a certain period of time and the received nursing care [1]. Many patients’ requiring long-term care hospitalizations are in psychiatric long-term-care beds and in longterm-care beds for the elderly if there is no change in the patient’s condition, the same information must be recorded repeatedly in the nursing summary. This is inefficient and costly for the nursing service. It has been noted that the information recorded is sometimes inadequate [6]
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