Decision Making and Documentation in Nursing (2op)

Osaamistavoitteet (Opintojakso)

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

Sisältö (Opintojakso)

- 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

Esitietovaatimukset (Opintojakso)

none

Aika ja paikka

54 hours of student's work

Tenttien ja uusintatenttien ajankohdat

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

Arviointimenetelmät ja arvioinnin perusteet

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

Arviointiasteikko

0-5

Opiskelumuodot ja opetusmenetelmät

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

Oppimateriaalit

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.

Opiskelijan ajankäyttö ja kuormitus

54 hours of student's work

Lisätietoja opiskelijoille

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

Arviointikriteerit - hylätty (0) (Ei käytössä, kts Opintojakson Arviointikriteerit ylempänä)

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

Arviointikriteerit - tyydyttävä (1-2) (Ei käytössä, kts Opintojakson Arviointikriteerit ylempänä)

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

Arviointikriteerit - hyvä (3-4) (Ei käytössä, kts Opintojakson Arviointikriteerit ylempänä)

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

Arviointikriteerit - kiitettävä (5) (Ei käytössä, kts Opintojakson Arviointikriteerit ylempänä)

-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