Analysis of nursing notes and mapping of nursing surveillance activities for patients who underwent…

StudyJournal of Korean biological nursing science· Aug 2025

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

Se Young Kim, Chunseon Jang, Moon Kyung Lee … Eunsim Kim

Hepatobiliary & Pancreatic SurgeryStudyQ3IF 0.6

Monitoring vital signs was the most frequently documented nursing surveillance activity after cholecystectomy.

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

Se Young Kim … Eunsim Kim

Journal of Korean biological nursing science · Aug 2025

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.

n = 1,082 patients

33,843

Results

33,843

vital sign checks were the top documented nursing surveillance activity

n = 1,082 patients

More results

In contrast, surveillance activities related to participation in decision-making and communication with physicians were relatively underdocumented.

“

Conclusion · 1 of 2

The mapping table developed in this study could increase the visibility of nursing surveillance activities and may be used as clinical education material.

Conclusion · 2 of 2

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.

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

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

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