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Trial of Converting Nursing Records into Simplified and Structured Information Utilizing ChatGPT-3.5
Ryoma Seto1, Masatoshi Ishikawa1, Hirona Okudaira2
1Healthcare Research Institute, Tokyo Healthcare University, Tokyo, Japan.
Abstract:
In Japan, the excessive length of time required for nursing records has become a social problem. A shift to concise "bulleted" records is needed to apply speech recognition and to work with foreign caregivers. Therefore, using 96,000 descriptively described anonymized nursing records, we identified typical situations for each information source and attempted to convert them to "bulleted" records using ChatGPT-3.5(For return from the operating room, Status on return, Temperature control, Blood drainage, Stoma care, Monitoring, Respiration and Oxygen, Sensation and pain, etc.). The results showed that ChatGPT-3.5 has some usable functionality as a tool for extracting keywords in "bulleted" records. Furthermore, through the process of converting to a "bulleted" record, it became clear that the transition to a standardized nursing record utilizing the "Standard Terminology for Nursing Observation and Action (STerNOA)" would be facilitated.
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Formats for Nursing Documentation
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,...
Data Collection II
Methods of Documentation III: PIE
Nursing Clinical Information System
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:
Methods of Documentation IV: Focus Charting
It typically involves three columns for recording information: