摘要: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.
关键词:Nursing Summary Document; Nursing Care Plan; Automatic Generation; PSYCHOMS