Study Guide

Objectives

The objective of this study module is to learn documentation in accordance with healthcare regulations in various healthcare settings.

After completing the course course, the student
• Understand the customer-oriented, ethical, and legislative foundations of documentation.
• Be able to create a structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care.
• Be able to assess patient data at various stages of the care process.
• Understand the basics of digital information and information management.

Content

• Customer-oriented documentation, ethics, legislation, and national guidelines.
• Different phases of the nursing process in structured recording.
• Creating a structured nursing care plan, documenting nursing care implementation, and summarizing nursing care.
• Systematic assessment of documentation at different stages.
• Citizen-generated information in the national data archive.

Assessment criteria, satisfactory (1-2)

The student:
• Understands the customer-oriented, 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.
• Understands how to assess patient data at different stages of the care process.
• Understands the basics of digital information and information management.

Assessment criteria, good (3-4)

The student:
• Understands the customer-oriented, ethical, and legislative foundations of documentation.
• Can create a customer-oriented structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care.
• Can assess patient data at different stages of the care process.
• Understands the basics of digital information and information management.

Assessment criteria, excellent (5)

The student:
• Can apply customer-oriented, ethical, and legislative foundations in documentation.
• Can create a customer-oriented structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care based on evidence-based information.
• Can comprehensively assess well-documented patient data at different stages of the care process.
• Can apply digital information and information management principles.