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2018 Fiscal Year Final Research Report

Study for a program of qualitative audit of electronic nursing record

Research Project

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Project/Area Number 16K11986
Research Category

Grant-in-Aid for Scientific Research (C)

Allocation TypeMulti-year Fund
Section一般
Research Field Fundamental nursing
Research InstitutionNagoya University (2018)
Kobe University (2016-2017)

Principal Investigator

Sugano Aki  名古屋大学, 医学部附属病院, 病院助教 (20457039)

Co-Investigator(Kenkyū-buntansha) 高岡 裕  神戸大学, 医学部附属病院, 准教授 (20332281)
藤原 由佳  神戸大学, 医学部附属病院, 看護師 (40314489)
Research Collaborator OHTA Mika  
Project Period (FY) 2016-04-01 – 2019-03-31
Keywords看護記録 / 診療録監査 / 自然言語処理
Outline of Final Research Achievements

In this study, we compared sentences in nursing records with that in newspaper articles in respect of the frequency of characteristic terms or their syntactic structures by means of morphological analysis and syntactic analysis. As a result, the frequency of verbs concerning communications or movements of patients was relatively high and the number of phrases in one sentence was relatively small in nursing records.

Free Research Field

病院・医療情報管理学

Academic Significance and Societal Importance of the Research Achievements

日本の保険医療において、診療録等の医療記録は診療報酬請求の根拠であり、適切に記載されるべきものである。また、近年、カルテや看護記録が電子化されるようになったが、現状ではシステムが記録の質を担保することは出来ない。そこで本研究では、看護記録に入力された文章を言語解析して記録監査に利用可能なその特徴の解明に取り組み、その特徴の一端を明らかにした。

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Published: 2020-03-30  

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