@inproceedings{oai:tau.repo.nii.ac.jp:00000032,
 author = {前田, 樹海 and 山下, 雅子 and 北島, 泰子 and 辻, 由紀 and 古澤, 圭壱 and MAEDA, JUKAI and YAMASHITA, MASAKO and KITAJIMA, YASUKO and TSUJI, YUKI and FURUSAWA, KEIICHI},
 book = {医療情報学, Japan journal of medical informatics},
 issue = {Suppl.},
 month = {},
 note = {The purpose of this research is to present a new way of nursing records based on nurses' tacit information processing.

It is well known among nurses that some experienced nurses can sense an impending outcome of patients such as death, aggravation of illness and so on despite being no changes in their vital signs. Our series of researches relating to tacit skill acquisition and tacit information process of nurses showed that they estimated such patient death based on the “signs” such as “somehow”, “countenance”, and “instinct” which were considered impossible to identify objectively in words.

SOAP is widely prevalent as a nursing record. When nurses enter their clinical judgment on the SOAP format, it is essential for them to write some data (SO) and the line of reasoning (A) to support the judgment. In other words, a judgment based on data which is impossible to be expressed verbally. In addition, SOAP format has a problem that nurses cannot write what nurses actually have done for the patients. However, our research also showed that such judgments were useful for nurses, for instance, confirmation of DNAR and how to contact doctors in charge, and getting in touch with patient's family. If the matters cannot be put on the nursing records only for the reason that they cannot write SOA on the form, we would have to say SOAP format is not suitable for nursing records.
For this reason, we researchers offer the following suggestions to improve the SOAP-format nursing record. These are 1) to establish a framework so that nurses can write what they have done after the Plan, and 2) to have a rule so that nurses can write the record starting at P without SOA. Those suggestions have the advantage that the characteristics of nurses' clinical judgment using inexpressible data or heuristics would become apparent on the records. On the other hand, there is concern that such changes may sabotage nurses' efforts to verbalize what they can verbalize. However, if we ensure the suitable operation of “description from P”, it would contribute not only to distinction between what to be verbalized and what not to be verbalized, but to education for clinical nurses.},
 pages = {634--635},
 publisher = {日本医療情報学会},
 title = {言語表出が不可能な根拠に基づく看護判断とその看護行為の記録に関する試案},
 volume = {35},
 year = {2015},
 yomi = {マエダ, ジュカイ and ヤマシタ, マサコ and キタジマ, ヤスコ and ツジ, ユキ and フルサワ, ケイイチ}
}