Generative AI-Based Nursing Diagnosis and Documentation Recommendation Using Virtual Patient Electronic Nursing Record Data
10.4258/hir.2025.31.2.156
- Author:
Hongshin JU
1
;
Minsul PARK
;
Hyeonsil JEONG
;
Youngjin LEE
;
Hyeoneui KIM
;
Mihyeon SEONG
;
Dongkyun LEE
Author Information
1. DKMediInfo, Hwaseong, Korea
- Publication Type:Original Article
- From:Healthcare Informatics Research
2025;31(2):156-165
- CountryRepublic of Korea
- Language:English
-
Abstract:
Objectives:Nursing documentation consumes approximately 30% of nurses’ professional time, making improvements in efficiency essential for patient safety and workflow optimization. This study compares traditional nursing documentation methods with a generative artificial intelligence (AI)-based system, evaluating its effectiveness in reducing documentation time and ensuring the accuracy of AI-suggested entries. Furthermore, the study aims to assess the system’s impact on overall documentation efficiency and quality.
Methods:Forty nurses with a minimum of 6 months of clinical experience participated. In the pre-assessment phase, they documented a nursing scenario using traditional electronic nursing records (ENRs). In the post-assessment phase, they used the SmartENR AI version, developed with OpenAI’s ChatGPT 4.0 API and customized for domestic nursing standards; it supports NANDA, SOAPIE, Focus DAR, and narrative formats. Documentation was evaluated on a 5-point scale for accuracy, comprehensiveness, usability, ease of use, and fluency.
Results:Participants averaged 64 months of clinical experience. Traditional documentation required 467.18 ± 314.77 seconds, whereas AI-assisted documentation took 182.68 ± 99.71 seconds, reducing documentation time by approximately 40%. AI-generated documentation received scores of 3.62 ± 1.29 for accuracy, 4.13 ± 1.07 for comprehensiveness, 3.50 ± 0.93 for usability, 4.80 ± 0.61 for ease of use, and 4.50 ± 0.88 for fluency.
Conclusions:Generative AI substantially reduces the nursing documentation workload and increases efficiency. Nevertheless, further refinement of AI models is necessary to improve accuracy and ensure seamless integration into clinical practice with minimal manual modifications. This study underscores AI’s potential to improve nursing documentation efficiency and accuracy in future clinical settings.
