Study Guide

Objective

After having completed the course you willknowthe duties of a health care professional to create, store and keep medical records secretthe laws and requirements considering creation, storage and data safety regulated via legislationhow to create data according to the rules concerning patient's medical recordsthe data safety standards considering medical information systems and nursingbe able to explainthe different phases of decision-making in nursing and to apply them in learning assignmentsthe model of national patient documentation and to use it in the creation of medical recordsbasic principles of patient acuity classification systembe able to use structured electronic information system at the patient documentationbe able to describe information management in health care and its significance on the patient and the health carerecognise and evaluate the opportunities of eSrvices and network medication and competence outcomes in nursingbe able to evaluate the contents of treatment plan, to use assessment tools and to evaluate the implementation of processing the medical care documentation safely

Content

Legislation that complies the data processing and its significance.Decision-making process in health caretreatment plan and documentation in the medical recordsFinCC classification unit and its implementationSummary of medical careTools for the evaluation of treatment planPatient acuityInformation management and its significance for nursingMaintenance and improvement of data securityBetter use of evidence-based instructions and recommendations in nursingeServices and network medication in nursingDemanded competences of clients and workers for eServices

Evaluation scale

H-5