护理记录
护理部
计算机科学
医学
梅德林
化学
生物化学
作者
Ryoma Seto,Masatoshi Ishikawa,Hirona Okudaira,Kai Ishida,Toshitaka Inoue,Susumu Wakabayashi,David Liu
摘要
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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