Course: Nursing Process and Documentation

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Course title Nursing Process and Documentation
Course code UZV/OK2OD
Organizational form of instruction Lecture + Seminar
Level of course Bachelor
Year of study not specified
Semester Summer
Number of ECTS credits 4
Language of instruction Czech
Status of course Compulsory
Form of instruction Face-to-face
Work placements This is not an internship
Recommended optional programme components None
Lecturer(s)
  • Schneider Michaela, PhDr. Ph.D., MBA
  • Kudlová Pavla, PhDr. Bc. Ph.D., MBA
Course content
Lectures - Nursing Process - Concept, Historical Development, Significance, and Application in Practice. Overview of Nursing Process Phases - 1 hour. - Nursing Needs - 2 hours. - Patient Assessment - Gathering Information about the Patient, Sources, Documentation - 1 hour. - Nursing Diagnosis, NANDA, NIC, NOC, ICNP Taxonomies - 2 hours. - Planning Nursing Care - Goal Formulation and Nursing Interventions Plan - 1 hour. - Implementation of Planned Care - Competencies of Individual Healthcare Team Members - 1 hour. - Evaluation of Nursing Care Effectiveness - 1 hour. - Nursing Documentation, Legal Aspects of Nursing Documentation - 1 hour. Class practice - Nursing Needs - 4 hours. - Assessment Steps (data collection, analysis, and organization, selection of potential diagnoses, assessment, prioritization of diagnoses). Methods of information and data collection - 3 hours. - Diagnostic process - formulating a nursing diagnosis - 3 hours. - Development of a nursing plan - Procedure for creating a nursing plan for a specific client (with modified identification data) - 3 hours. - Implementation of nursing care - 1 hour. - Evaluation - 1 hour. - Health documentation. Record keeping in nursing documentation, practice documentation. Working with documentation in a specific department - 5 hours.

Learning activities and teaching methods
Lecturing, Monologic (Exposition, lecture, briefing), Dialogic (Discussion, conversation, brainstorming), Methods for working with texts (Textbook, book), Observation, Demonstration, Practice exercises, Text analysis, Self-reflection, Students working in pairs, Dealing with situational issues - learning in situations
  • Participation in classes - 25 hours per semester
  • Home preparation for classes - 40 hours per semester
  • Term paper - 20 hours per semester
  • Preparation for examination - 20 hours per semester
learning outcomes
Knowledge
describe and explain in your own words the nursing process and needs
describe and explain in your own words the nursing process and needs
describe the historical development and individual phases of the nursing process
describe the historical development and individual phases of the nursing process
identify unmet needs, nursing problems of the client
identify unmet needs, nursing problems of the client
list the parts of the medical documentation and clarify its meaning
list the parts of the medical documentation and clarify its meaning
explain the principles of nursing documentation management
explain the principles of nursing documentation management
Skills
asses needs, take an anamnesis, perform a physical examination of a specific patient/client
asses needs, take an anamnesis, perform a physical examination of a specific patient/client
evaluate the condition of the patient/client
evaluate the condition of the patient/client
formulate nursing diagnoses
formulate nursing diagnoses
draw up a nursing plan for the goals of care for a specific patient/client
draw up a nursing plan for the goals of care for a specific patient/client
make correct entries in the nursing documentation
make correct entries in the nursing documentation
teaching methods
Knowledge
Dialogic (Discussion, conversation, brainstorming)
Demonstration
Demonstration
Methods for working with texts (Textbook, book)
Methods for working with texts (Textbook, book)
Observation
Observation
Text analysis
Text analysis
Self-reflection
Self-reflection
Practice exercises
Practice exercises
Students working in pairs
Students working in pairs
Dealing with situational issues - learning in situations
Dealing with situational issues - learning in situations
Lecturing
Lecturing
Monologic (Exposition, lecture, briefing)
Monologic (Exposition, lecture, briefing)
Dialogic (Discussion, conversation, brainstorming)
assessment methods
Written examination
Analysis of the student's performance
Analysis of the student's performance
Analysis of another type of paper written by the student (Casuistry, diary, plan ...)
Analysis of another type of paper written by the student (Casuistry, diary, plan ...)
Written examination
Analysis of seminar paper
Analysis of seminar paper
Recommended literature
  • Kontakt, Profese, Ošetřovatelství a porodní asistence, British Journal of Nursing, RN, Nursing aj..
  • BULECHEK, G. M., BUTCHER, H. K., DOCHTERMAN, J. M. Nursing Interventions Classification (NIC). Mosby, 2008. ISBN 978-0-323-05340-2.
  • HERDMAN, T. H., KAMITSURU, S. (eds.). Ošetřovatelské diagnózy: definice a klasifikace 2018-2020. Prah: Grada, 2020.
  • HERDMAN, T.H. & KAMITSURU, S., překlad Pavla Kudlová. NANDA International, Inc. OŠETŘOVATELSKÉ DIAGNÓZY: Definice a klasifikace 2015-2017. Praha: Grada, 2015. ISBN 978-80-247-5412-3.
  • Kolektiv autorů. Průvodce ošetřovatelskou dokumentací od A do Z. 1. vyd. Praha: Grada Publishing, 2002. ISBN 80-247-0278-9.
  • KUDLOVÁ, P. a J. MAREČKOVÁ. Ošetřovatelská dokumentace, plán ošetřovatelské péče ? výstup 3. fáze ošetřovatelského procesu. Olomouc: Grada, 2004.
  • KUDLOVÁ, P. Historie ošetřovatelského procesu a ošetřovatelských diagnóz NANDA. In Ošetřovatelství - morální umění. Krátká, Kutnohorská, Cichá a kol. Praha: Grada, 2011. ISBN 978-80-247-4201-4.
  • MASTILIAKOVÁ, D. Posuzování stavu zdraví a ošetřovatelská diagnostika: v moderní ošetřovatelské praxi. Praha: Grada, 2014.
  • MOORHEAD, S. Nursing Outcomes Classification (NOC). Oxford: MOSBY ELSEVIER, 2012. ISBN 978-0-323-05408-9.
  • NEJEDLÁ Marie. Fyzikální vyšetření pro sestry. Praha: Grada, 2006. ISBN 80-247-1150-8.
  • PACOVSKÝ, V. Ošetřovatelská diagnostika. Praha: UK, 1985.
  • TÓTHOVÁ, Valerie a kol. Ošetřovatelský proces a jeho realizace. Praha: Triton, 2014. ISBN 978-80-7387-785-9.
  • TRACHTOVÁ, E. et al. Potřeby nemocného v ošetřovatelském procesu. 2. vyd. Brno: IDVPZ, 2001.
  • VAŠÁTKOVÁ, I. a kol. Ošetřovatelská dokumentace v nemocnici. Brno: IDVPZ, 2001. ISBN 80-7013-327-9.


Study plans that include the course
Faculty Study plan (Version) Category of Branch/Specialization Recommended year of study Recommended semester