Analysis of nursing notes and mapping of nursing surveillance activities for patients who underwent cholecystectomy in Korea: a retrospective descriptive study

Purpose This study aimed to systematically extract keywords from the electronic nursing notes of patients who underwent cholecystectomy and to develop a mapping table to identify nursing surveillance activities. Methods This retrospective study was conducted using the electronic medical records of 1,082 patients who underwent cholecystectomy between January 2022 and September 2023 at a tertiary hospital in South Korea. Natural language processing was used to extract keywords from nursing notes (in the data, action, and response [DAR] format). Sixteen surveillance activity items were used to map nursing surveillance activities based on the nursing notes. The manually developed mapping table was validated through repeated reviews and consensus among the research team. Results The most frequently extracted keywords were “pain” and “NRS (Numeric Rating Scale).” The most frequently recorded nursing surveillance activities were “monitor vital signs, as appropriate” (n = 33,843), “monitor coping strategies used by the patient and their family” (n = 33,666), and “anticipate potential problems based on overall judgments of patient data” (n = 8,049). In contrast, surveillance activities related to participation in decision-making and communication with physicians were relatively underdocumented. Conclusion The mapping table developed in this study could increase the visibility of nursing surveillance activities and may be used as clinical education material. Furthermore, the findings provide insights into the scope and characteristics of nursing surveillance activities performed in actual clinical settings, and areas for improvement in future practice are suggested.