Related Concept Videos
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
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A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
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01:30Guidelines for Nursing Documentation I
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Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
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01:29Documentation in Long-Term and Home Healthcare Setting
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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Long-Term Care Facilities
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01:26Guidelines for Nursing Documentation II
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Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
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01:10Documentation of Nursing Diagnosis
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The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
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01:28Formats for Nursing Documentation
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Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
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Machine learning-based speech recognition system for nursing documentation - A pilot study.
Tso-Ying Lee1, Chin-Ching Li2, Kuei-Ru Chou3
1Director of Nursing Research Center, Nursing Department, Taipei Medical University Hospital, Taipei, Taiwan; Associate Professor, School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.
International Journal of Medical Informatics
|September 10, 2023
Summary
A machine learning-based speech recognition system shows promise in reducing nursing documentation workload. The system achieved improved accuracy over four sessions, suggesting potential for enhanced efficiency in clinical record-keeping.
Keywords:
Artificial IntelligenceDictationNatural language processingNursing DocumentationSpeech RecognitionMore Related Videos
Area of Science:
- Clinical Informatics
- Artificial Intelligence in Healthcare
- Nursing Technology
Background:
- Nursing documentation is a significant workload contributor.
- Efficient record-keeping is crucial for effective patient care and hospital operations.
- Existing documentation methods can be time-consuming for nursing staff.
Purpose of the Study:
- To evaluate a machine learning-based speech recognition (SR) system's effectiveness.
- To assess the system's impact on reducing clinical workload for nurses typing records.
- To test the SR system in a real-world psychiatry ward setting.
Main Methods:
- A deep learning-based SR engine was trained using hospital nursing data.
- 21 nurses evaluated the SR system alongside traditional keyboard entry.
- Documentation time and recognition error rates were compared across four sessions.
Main Results:
- The SR system processed over 30,000 words with increasing accuracy.
- Mean accuracy improved from 87.06% in the first session to 95.07% in the fourth.
- The system demonstrated an average processing speed of 0.928 words per second.
Conclusions:
- The machine learning-based SR system shows acceptable accuracy and potential to alleviate nursing documentation burden.
- Continuous improvement is needed to address SR transcription errors.
- Further research is required for optimal integration of SR in nursing digital records across specialties.