Decision Making and Documentation in Nursing (2cr)

Objectives (course unit)

The student
- knows the main principles of documentation;
- is able to apply the nursing process;
- knows the nursing plan and is able to plan patient care in hospital and in outpatient health care;
- knows and is able to apply the legislation concerning documentation;
- understands nurses' responsibility in documentation and information management

Content (course unit)

- development of documentation in nursing, utilisation of accumulative patient information, and digital health care services;
- legislation;
- patient information records;
- the nursing process;
- structured documentation, FinCC;
- evaluation, nursing summary and nursing plan

Prerequisites (course unit)

none

Location and time

54 hours of student's work

Exam schedules

Course exam 26 March 2019
Retake 1 in April on Exam
Retake 2 in May on Exam

Assessment methods and criteria

Graded evaluation (0-5)
-participation in classes
-mandatory participation in orientation, small group work, seminar
-Online courses, Tabula tasks, Docca- tasks completed with approved mark
-graded written test, including multiple choice part with 75% of points for completion

Assessment scale

0-5

Teaching methods

Lectures, group work, individual work, online courses, tasks and discussions.

Learning materials

Yoost, B, Crawford, L& Peterson, V. 2015 Clinical companion for fundamentals of nursing : active learning for collaborative practice: chapters 10 and 11. e- book.
Marshall, Lori C., and Sigma Theta Tau International. Mastering Patient and Family Education: A Healthcare Handboook for Success. Sigma Theta Tau International, 2016.
Chapter 11: Cordero & Marshall:Patient-Family Education Documentation Processes and Systems. Documentation Processes and Systems. e-book
Other course material will be presented at the mandatory orientation.

Student workload

54 hours of student's work

Further information

Contents:
- legislation, protocols, Data Protection Regulation
- Kanta- database, patient records archive, medicines records, (kanta.fi)
- Nursing Process
- structured documentation, nursing structure according to FinCC
- assessment and evaluation of nursing care plans, nursing care summary, health and care plan
- development of nursing documentation, utilization of existing client documents

Assessment criteria - fail (0) (Not in use, Look at the Assessment criteria above)

Does not meet the criteria for satisfactory work.
Is not present in Orientation or small group work.
Does not complete tasks.

Assessment criteria - satisfactory (1-2) (Not in use, Look at the Assessment criteria above)

The student
- knows the phases of nursing process and can make a nursing care plan
-knows the main features of legislation guiding documentation
-recognises the principles of nursing documentation
-recognises digital health services and can guide citizens to use those
-recognises the use of evidence based knowledge supporting decision making in nursing and among citizens

Assessment criteria - good (3-4) (Not in use, Look at the Assessment criteria above)

The student
- can describe several phases of nursing process and can make an individual nursing care plan
- can describe impacts of legislation guiding documentation on professional conduct
-can ponder roles of patients and nursing professionals in decision making and documentation
-recognises the principles of nursing documentation
-recognises digital health services and can guide citizens to use those
-recognises the use of evidence based knowledge supporting decision making in nursing and among citizens

Assessment criteria - excellent (5) (Not in use, Look at the Assessment criteria above)

-is able to implement with rationales phases of nursing process in making an individual, comprehensive and logical nursing care plan
- is able to utilise legislation as a part of professional pondering of nursing documentation
-is able to assess roles of patients and nursing professionals in decision making and documentation
-is able to implement principles of nursing documentation
-recognises national digital health services and can guide citizens to use those
- is able to implement and utilise evidence based knowledge supporting decision making in nursing and among citizens