SAQA All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.
SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Maintain current records according to the scientific nursing process 
SAQA US ID UNIT STANDARD TITLE
120170  Maintain current records according to the scientific nursing process 
ORIGINATOR
SGB Nursing 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 09 - Health Sciences and Social Services Curative Health 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 3  NQF Level 03 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Reregistered  2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This unit standard will enable learners to maintain accurate and appropriate records of nursing care. This is essential for all health care workers at this level, as accurate assessment and record keeping will enable all members of all levels of the multidisciplinary health care team to gain knowledge of the patient and the patient's reactions, thereby contributing to the creation of a therapeutic milieu and speeding up the patient's recovery.

Learners credited with this unit standard will be able to:
  • Record patient information according to institutional, professional and legal standards.
  • Record accurately nursing observations, actions and changes in patient condition.
  • Handle patient and unit records in a responsible manner.

    The learner will function within the scope of practice of an enrolled auxiliary nurse as formulated by the South African Nursing Council regulations, institutional policies related to specific occupational settings as well as the parameters of the capabilities of the learner at this level. 

  • LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    Learners starting with this standard are expected to be competent in:
  • Mathematical literacy at NQF Level 2.
  • Communication at NQF Level 2. 

  • UNIT STANDARD RANGE 
    N/A 

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Record patient information according to institutional, professional and legal standards. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Patient information is recorded according to the following required standards:
  • Institutional, e.g. format, components.
  • Professional, e.g. ethical, use of abbreviations.
  • Legal, e.g. indelible, accurate, legible, signed, dated. 

  • SPECIFIC OUTCOME 2 
    Record accurately nursing observations, actions and changes in patient condition. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Nursing observations and actions are reflected accurately, systematically and concisely on the patient's record on a continuous basis. 

    SPECIFIC OUTCOME 3 
    Handle patient and unit records in a responsible manner. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Confidentiality of patient records is maintained by storing the records in a controlled area. 

    ASSESSMENT CRITERION 2 
    Patient and unit records are maintained according to institutional policy. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    N/A 

    UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
  • Principles of documentation within a health care setting.
  • Legal requirements of documentation.
  • Professional and ethical requirements.
  • Policies.
  • Information technology. 

  • UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
  • Record patient information according to institutional, professional and legal standards.
  • Record accurately nursing observations, actions and changes in patient condition. 

  • UNIT STANDARD CCFO WORKING 
  • Handle patient and unit records in a responsible manner. 

  • UNIT STANDARD CCFO ORGANISING 
  • Record patient information according to institutional, professional and legal standards.
  • Record accurately nursing observations, actions and changes in patient condition.
  • Handle patient and unit records in a responsible manner. 

  • UNIT STANDARD CCFO COLLECTING 
  • Record patient information according to institutional, professional and legal standards.
  • Record accurately nursing observations, actions and changes in patient condition.
  • Handle patient and unit records in a responsible manner. 

  • UNIT STANDARD CCFO COMMUNICATING 
  • Record patient information according to institutional, professional and legal standards.
  • Record accurately nursing observations, actions and changes in patient condition. 

  • UNIT STANDARD CCFO SCIENCE 
  • Record patient information according to institutional, professional and legal standards.
  • Record accurately nursing observations, actions and changes in patient condition.
  • Handle patient and unit records in a responsible manner. 

  • UNIT STANDARD CCFO DEMONSTRATING 
  • Record patient information according to institutional, professional and legal standards.
  • Record accurately nursing observations, actions and changes in patient condition.
  • Handle patient and unit records in a responsible manner. 

  • UNIT STANDARD CCFO CONTRIBUTING 
  • Record patient information according to institutional, professional and legal standards.
  • Record accurately nursing observations, actions and changes in patient condition.
  • Handle patient and unit records in a responsible manner. 

  • UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    Integrated Assessment:

    The South African Nursing Council guidelines are used as a reference for clinical competence.

    Formative:

    A variety of assessment strategies and/or approaches must be used. These could be, but are not limited to:
  • Tests
  • Assignments
  • Workbooks
  • Projects
  • Demonstrations
  • Clinical assessments

    Summative:

    May take the form of:
    > written
    > practical
    > oral assessment
    as agreed to by the relevant ETQA or ETQA that has a Memorandum of Understanding in place with the relevant ETQA.

    Matrix to indicate how credits are derived:

    Learning experience:
  • Theoretical Learning: 20 hours, 2 credits
  • Experiential Learning: 30 hours, 3 credits
  • Total: 50 hours, 5 credits 

  • QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Core  71709   National Certificate: Auxiliary Nursing  Level 3  NQF Level 03  Reregistered  2023-06-30  As per Learning Programmes recorded against this Qual 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    NONE 



    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.