Organization of nursing process and documentation in nursing (3op)

Osaamistavoitteet

Master student is able to collect the patient information and to define the care needs of the patient, set patient centered goals, and document the patient centered implementation, and assess the nursing care.
He/she is able to implement and develop the patient centered nursing documentation according to the best international practices research data, and professional ethical principles.
Master student reflects his/her experiences of different theories or models of nursing, and how they are connected to the nursing process and documentation.
He/she is able to explain the importance of the nursing process and its connections to the national health care development programme and professional standards, and is able to improve the implementation of the process.
Master student is able to explain the nurse’s role in communication and documentation in a care team, and give examples of the new innovative technologies used in documentation.

Sisältö

Description of the nursing process.
Documentation of the nursing process according to the international practices (data collection, prioritization of the care needs, implementation of nursing interventions, assessment).
Theories and models of nursing connections to nursing process and documentation.
Standards and protocols of nursing practice and connections to documentation.
Nurses’ professional role and ethics in patient centered clinical documentation.
New electronic information technologies used in the nursing documentation.
Nurse as a coordinator of the nursing process.
Effective communication in a multiprofessional care team.

Arviointikriteerit, tyydyttävä (1)

Pass
Master student is able to explain the nursing process, and its connections to the nursing theories and/or models with good examples. She / he is also able to make the connections to the international best practices and national requirements in documentation in order to develop the documentation. Master student is able to do the patient centered documentation, and is able to present the improvement methods for practice based on research data. Master student is able to explain the nurses’ role in communication and documentation in a care team, and gives examples of the new innovative technologies used in documentation (BC4).

Fail
Master student is able to explain parts of the nursing process, gives unclear connections to the nursing theories and/or models. She / he is also able to make the connections to the international practices and national requirements in documentation but has difficulties to use that information to develop the documentation. Master student is able to do the patient centered documentation partially or not at all, and is presenting some improvement methods for practice which are vaguely based on research data. Master student explains the nurses’ role in communication and documentation in a care team partially, and gives few examples of the new existing technologies used in documentation (BC4).