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Nursing Documentation (2 cr)

Code: 7Q00FP62-3007

General information


Enrolment period

03.06.2022 - 31.08.2022

Timing

01.08.2022 - 31.12.2022

Credits

2 op

Mode of delivery

Contact teaching

Unit

Nursing

Campus

TAMK Main Campus

Teaching languages

  • English

Degree programmes

  • Bachelor's Degree Programme in Nursing

Teachers

  • Tuuli Uusitalo

Person in charge

Sanna Laiho

Groups

  • 22NURFILTOP

Objectives (course unit)

The Student
- knows the customer-oriented, ethical and legal principles of documentation
- is able to prepare a structured care plan and a summary of care plan according to the process
- understand the basics of digital information and information management

Content (course unit)

- the nursing process
- structured information on nursing and information produced by the citizen in the national data archive
- documentation ethics and legislation and guidance
- structured nursing documentation, nursing plan and nursing summary

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

The student
- knows the customer-oriented, ethical and legal principles of documentation
- is able to prepare a structured care plan and a summary of care plan according to the process
- knows the basics of digital information and information management

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

The student
- knows the customer-oriented, ethical and legal principles of documentation
- is able to independently prepare a customer-oriented structured care plan and a summary of care plan according to the process

Assessment criteria, excellent (5) (course unit)

The student
- is able to apply customer-oriented, ethical and legal principles in documentation
- is able to prepare independently and evidence-based information, applying a process-oriented structured care plan and a summary of care plan according to the process
- is able to apply digital information and information management principles

Location and time

Autumn term 2022 at TAMK.

Exam schedules

Exam: weeks 44-45
Re-exam 1: weeks 49-50
Re-exam 2: weeks 4-5 (spring 2023)

Duration of the exam 45 min. The passing limit is 50% correct.

Exams will be arranged in the exam environment. There will be two possibilities to re-take the exam following the initial exam. Nursing care plan submissions on docca are also part of the assessed course work and need to be submitted in line with information provided in the orientation session. Docca assignment will be submitted as part of clinical practice. All allocated tasks must be submitted within the given timeframe for the course.

Assessment methods and criteria

All the assigned tasks are mandatory. All tasks must be completed by the end of the course.

-Participation mandatory teaching, obligation to attend an orientation class
-The obligation to be present in small group work and to make an exercise management plan approved
-Online exam, numerical assessment. Approved completion of various parts of the exam. In the multiple choice section, the pass requirement is 50% correct.
-Acceptance of assigned tasks approved

Student:
· Knows the general principles of nursing documentation
· Knows the stages of the nursing process and understands the differences between them
· Is able to prepare a care plan and a summary of nursing work
· Is familiar with the structured recording of nursing and is able to use it in nursing as part of patient care
· Knows the structure of a health and care plan
· Use evidence-based information to support decision-making
· Knows and is able to apply the legislation governing registration
· Understand the nurse's responsibility in documenting and managing information
· Is interested in the development of the digital social and health sector

Assessment scale

0-5

Teaching methods

Lectures, small group work, assignments, independent study.

Creating a treatment plan for the Docca training platform as a part of the clinical training.

Learning materials

Course material will be presented in the mandatory orientation. Relevant materials will be distributed by the teacher.

Student workload

54 hours of which 12 hours theory and 4 hours of practicing Docca treatment plan making.
38 hours of students independed work.

Content scheduling

The course is structured as follows: theory, tasks, indivual work, group work, Docca treatment plan as a part of clinical training. All components must be completed successfully in order to pass the course.

Content Sequencing (Parts)
· Theory (2 cr)
· Assignments (0 cr)
· Making a treatment plan (0 cr)

Further information

Student participation is mandatory in the following classes: orientation, legislation class and treatment plan workshop session. The dates of these will be advised in the orientation session.

Advanced course content:
· Kanta services
· Patient data and the use of data generated by citizens, professionals and technology
· The nursing process
· Preparation and evaluation of nursing plans in hospital and outpatient care, summary of nursing work
· Health and care plan
· Legislation, guidelines and documentation ethics
· Structures in nursing documentation
· Development of nursing documentation