Study Guide

Objectives (course unit)

The objective of this study module is to learn documentation in accordance with healthcare regulations in various healthcare settings.

After completing the course course, the student
• Understand the customer-oriented, ethical, and legislative foundations of documentation.
• Be able to create a structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care.
• Be able to assess patient data at various stages of the care process.
• Understand the basics of digital information and information management.

Content (course unit)

• Customer-oriented documentation, ethics, legislation, and national guidelines.
• Different phases of the nursing process in structured recording.
• Creating a structured nursing care plan, documenting nursing care implementation, and summarizing nursing care.
• Systematic assessment of documentation at different stages.
• Citizen-generated information in the national data archive.

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

The student:
• Understands the customer-oriented, ethical, and legislative foundations of documentation.
• Can create a structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care.
• Understands how to assess patient data at different stages of the care process.
• Understands the basics of digital information and information management.

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

The student:
• Understands the customer-oriented, ethical, and legislative foundations of documentation.
• Can create a customer-oriented structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care.
• Can assess patient data at different stages of the care process.
• Understands the basics of digital information and information management.

Assessment criteria, excellent (5) (course unit)

The student:
• Can apply customer-oriented, ethical, and legislative foundations in documentation.
• Can create a customer-oriented structured care plan in accordance with the nursing process, document the implementation of nursing care, and compile a summary of nursing care based on evidence-based information.
• Can comprehensively assess well-documented patient data at different stages of the care process.
• Can apply digital information and information management principles.

Assessment scale

0-5