Study Guide

Objectives

The objective of the course is to learn documentation in accordance with healthcare regulations in various healthcare settings. 

After completing the course, the student
• understands the client-centered, ethical, and legislative foundations of documentation in Finland
• can create a structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care 
 • can evaluate the compiled patient information at various stages of the care process 
• understands the basics of digital information and information management 
 • understands commonly used Finnish classifications and phrases related to structured documentation
• can make nursing documentation in Finnish according to their own language proficiency level, using simple phrases and sentences

Content

• client-centricity, ethics, Finnish legislation in documentation and Finland’s national guidelines 
• different stages of the nursing process in structured documentation 
• creating a structured nursing care plan, documenting the implementation of nursing care, and summarizing nursing care 
• systematic evaluation of documentation at different stages 
• the information produced by the citizen in the national data archive in Finland
• structured documentation using Finnish classifications and phrases

Assessment criteria, satisfactory (1-2)

The student
• understands the client-centered, ethical, and legislative foundations of documentation
• can create a structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care 
• knows how the compiled patient information is evaluated at various stages of the care process 
• understands the basics of digital information and information management

Assessment criteria, good (3-4)

The student
• knows the client-centered, ethical and legislative foundations of documentation 
• can create a process-based structured care plan, document the implementation of nursing care, and compile a summary of nursing care 
• can evaluate the compiled patient information at various stages of the care process 
• knows the basics of digital information and information management 

Assessment criteria, excellent (5)

The student  
• can apply client-centered, ethical, and legislative foundations in documentation 
• can create a process-based and client-centered structured care plan, document the implementation of nursing care, and compile a summary of nursing care based on evidence 
• can comprehensively evaluate the extensively compiled patient information at various stages of the care process 
• can apply digital information and information management 
• can implement structured nursing documentation using the Finnish language