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Hoitotyön prosessi ja sen dokumentointi (2 cr)

Code: 7K00DX24-3005

General information


Enrolment period
16.09.2019 - 15.10.2019
Registration for the implementation has ended.
Timing
21.10.2019 - 31.12.2019
Implementation has ended.
Credits
2 cr
Mode of delivery
Contact learning
Campus
TAMK Main Campus
Teaching languages
Finnish
Degree programmes
Degree Programme in Emergency Care
Teachers
Terhi Pekkinen
Person in charge
Terhi Pekkinen
Small groups
Pienryhmä 1 (Size: 13 . Open UAS : 0.)
Pienryhmä 2 (Size: 13 . Open UAS : 0.)
Small groups
Pienryhmä 1
Pienryhmä 2
Course
7K00DX24

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

Numeerinen arviointi (0-5)
Verkkotentti examissa (linkki kurssin tabulassa) Kokeen kesto 90 min.
1. uusinta, examissa, sovitaan opettajan kanssa
2. uusinta, examissa, sovitaan opettajan kanssa

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

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

Learning materials

Kaikki kurssimateriaali tabulapohjalla (ei hankittavaa tai lainattaa kirjallisuutta)
Kanta-palveluiden verkkokoulu https://verkkokoulut.thl.fi/web/kanta
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

Student workload

Teoriaopetusta 12 h
4 h pienryhmäharjoituksia

Itsenäiset tehtävät

Opiskelijalle laskettu työmäärä on 54 h kurssin asioiden hallitsemiseksi.

Content scheduling

· teoria (2 op)
· tehtävät (0 op)
· pienryhmätyöskentely (0 op)

Completion alternatives

Ei ole

International connections

Ei ole

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

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