Refereed journal article or data article (A1)

Assisting nurses in care documentation: from automated sentence classification to coherent document structures with subject headings

List of Authors: Moen Hans, Hakala Kai, Peltonen Laura-Maria, Matinolli Hanna-Maria, Suhonen Henry, Terho Kirsi, Danielsson-Ojala Riitta, Valta Maija, Ginter Filip, Salakoski Tapio, Salanterä Sanna.

Publisher: BioMed Central Ltd.

Publication year: 2020

Journal: Journal of Biomedical Semantics

Volume number: 11

Issue number: 1

Number of pages: 12

ISSN: 2041-1480

eISSN: 2041-1480


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Up to 35% of nurses' working time is spent on care documentation.
We describe the evaluation of a system aimed at assisting nurses in
documenting patient care and potentially reducing the documentation
workload. Our goal is to enable nurses to write or dictate nursing notes
in a narrative manner without having to manually structure their text
under subject headings. In the current care classification standard used
in the targeted hospital, there are more than 500 subject headings to
choose from, making it challenging and time consuming for nurses to use.


The task of the presented system is to automatically group
sentences into paragraphs and assign subject headings. For
classification the system relies on a neural network-based text
classification model. The nursing notes are initially classified on
sentence level. Subsequently coherent paragraphs are constructed from
related sentences.


Based on a manual evaluation conducted by a group of three domain
experts, we find that in about 69% of the paragraphs formed by the
system the topics of the sentences are coherent and the assigned
paragraph headings correctly describe the topics. We also show that the
use of a paragraph merging step reduces the number of paragraphs
produced by 23% without affecting the performance of the system.


The study shows that the presented system produces a coherent and
logical structure for freely written nursing narratives and has the
potential to reduce the time and effort nurses are currently spending on
documenting care in hospitals.

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Last updated on 2022-07-04 at 18:02