The Development of the “Monitoring Application for Inappropriate Expressions in Nursing Records” for PsyNACS©

Lengthening periods of hospitalization, increasing numbers of patients with age-related complications, and a shortage of nursing staff have been of great concern in medical psychiatry in Japan. Under these circumstances, countries such as Japan that face a super-aging society and a decline in the working-age population, have been recommended for use of advanced information and communications technology (ICT) to improve the efficiency of medical treatment and care. This study aims to develop the “Monitoring Application for Inappropriate Expressions in Nursing Records” for using PsyNACS©, which will enable psychiatric nursing plans to harness the advantages of ICT. The functions considered necessary are as follows: 1) identification of users who enter information; 2) a necessary database for lists of inappropriate expressions; 3) development of a matching function to recommend proper writing input and a warning function; and 4) a management function for an inappropriate expression list database. A demonstration experiment for developing the application in this study was conducted at a specialized psychiatric hospital. To introduce them to the application, nurses and nurse managers were informed about the system developed in this study, and a survey regarding their opinions on the functions of the application was conducted with ten nurse managers. The results were evaluated in terms of usefulness for nursing care, documentation, and the education of nurses from an ethical perspective. This study suggests that matching their input with an inappropriate expression database will allow nurses to record more appropriate expressions. From an ethical perspective, the ability to use appropriate expressions makes records more likely to withstand disclosure requests from patients and their families.

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