14.2.3.10 SN2209 Documentation in Nursing 4 CR / 6 ECTS CR

Objective and content
The student is aware of the instructions and regulations for compiling and keeping patient documents and of the meaning of the documents from both the patient’s and the health care staff’s legal right point of view. The student understands and is able to justify the meaning of documentation for guaranteeing patient oriented care, patient safety, continuity of care, quality of care and multi-professional teamwork. The student is able to accurately record the patient’s care process in the documents so that the documentation is justified and it evaluates and describes the essence of the care. The student will develop in taking advantage of information technology as a tool for documentation in nursing. He / she takes into consideration confidentiality questions both from the point of view of the patient and the nursing staff.