Nursing Process and Documentation (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 viikolla 33-35, Kokeen kesto 90 min.
1. uusinta, examissa viikolla 38
2. uusinta, examissa 43

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. Myöhässä palautetut tehtävät vaikuttavat arvosanaan laskevasti.

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