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
