Hoitotyön prosessi ja sen dokumentointi (2 cr)

Objectives (course unit)

The student
- knows the main principles of documentation
- knows the phases of the nursing process and understands the differences therein
- can make a nursing care plan and summary of the plan
- knows the structured nursing care plan and knows how to use it as part of the patient care
- knows the structure of a health and care plan
- uses evidence-based knowledge as part of the decision-making
- knows and is able to apply the legislation concerning documentation
- understands the nurse's responsibility in documentation and information management
- becomes interested in the development of digital social and health care.

Content (course unit)

- development of the documentation in nursing; utilisation of cumulative patient information and digital health care services;
- digital healthcare services and the potential of electronic applications
- the client data archive
- the nursing process
- making a nursing care plan, evaluation in the hospital and out-patient clinic
- health- and nursing-care plans
- legislations and instructions
- structured nursing documentation
- eHealth strategy of the Finnish Nurses Association

Assessment criteria, satisfactory (1-2) (course unit)

The student
- identifies digital health services and can guide citizens to use them
- understands the principles of nursing documentation
- knows the steps of nursing documentation and is able to make a nursing care plan
- knows the laws governing documentation
- recognises the use of evidence-based practice as supporting the decision-making process of a citizen and a nursing professional
- knows the role of a professional in nursing decision-making and documentation
- demonstrates interest in the development of digital social and health services.

Assessment criteria, good (3-4) (course unit)

The student
- is aware of national digital health services and can guide citizens to use them
- knows the basic principles of nursing documentation
- can describe the steps of nursing documentation and is able to make an individual nursing care plan
- is able to explain the effects of legislation concerning the documentation governing professional activities
- recognises the use of evidence-based practice as supporting the decision-making process of a citizen and a nursing professional
- is able to reflect on the role of a professional in nursing decision making and documentation
- is able to act responsibly in documentation and information management
- demonstrates familiarity with digital social and health care development.

Assessment criteria, excellent (5) (course unit)

The student
- recognises national digital health services and can guide citizens to use them, now and in the future
- can apply the principles of nursing documentation
-is able to apply with full understanding the steps of nursing documentation and can make an individual, comprehensive and logical nursing care plan
- is able to apply the legislation as part of a professional discussion of documentation
- can apply evience-based knowledge to support nursing decision making
- is able to reflect on the role of a professional in nursing decision making and documentation
- knows how to guide others in documentation and information management.

Exam schedules

Verkkotentti examissa 11.10. - 1.11.2019 Kokeen kesto 90 min.
1. uusinta, examissa 18.11. - 30.11.2019
2. uusinta, examissa 9.12. - 21.12.2019

Assessment methods and criteria

Osallistuminen opetukseen, orientaatiotunnilla ja pienryhmätyöskentelyssä läsnäolovelvollisuus
Verkkotentti, numeerinen arviointi. Tentin eri osien hyväksytty suoritus ja monivalintaosuudessa läpäisyvaatimuksena 75% oikein.
Annettujen tehtävien suorittaminen hyväksytysti.

Assessment scale

0-5

Teaching methods

Luennot, pienryhmätyöskentely, verkkokurssit, itsenäinen opiskelu. Kurssin ensimmäisellä tunnilla ja pienryhmätyöskentelyssä läsnäolovelvollisuus.

Learning materials

Kirjallisuus:
Kanta-palveluiden verkkokoulu https://verkkokoulut.thl.fi/web/kanta
Kurssimateriaali tabulapohjalla
Potilastiedon rakenteisen kirjaamisen opas. Osa1. 2018. https://thl.fi/documents/920442/2902744/Kirjaamisopas+osa+1++final+2018__.pdf/5395585e-324f-4ac5-86d6-106e27979e77
Potilasasiakirjojen laatiminen ja käsittely. Opas terveydenhuollolle. STM.2012. http://urn.fi/URN:ISBN:978-952-00-3337-8
Luennot
Muu opettajan osoittama materiaali

Student workload

54 h opiskeijan työtä

Content scheduling

Sisällön jaksotus (osat)
• teoria (2 op)
• tehtävät (0 op)
• pienryhmätyöskentely (0 op)

Completion alternatives

Ei ole

Practical training and working life cooperation

-

International connections

-

Further information

Opintojakson tarkennettu sisältö:
Kanta palvelut
Kansalaisen, ammattilaisen ja teknologian keinoin tuotettu potilastieto ja tiedon hyödyntäminen
Hoitotyön prosessi
Hoitotyön suunnitelmien laatiminen ja arviointi sairaalassa ja avohoidossa, hoitotyön yhteenveto
Terveys- ja hoitosuunnitelma
Lainsäädäntö, ohjeistus ja dokumentoinnin etiikka
Rakenteet hoitotyön dokumentoinnissa
Hoitotyön dokumentoinnin kehittyminen
Sairaanhoitajaliiton sähköisten terveyspalveluiden strategia