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: 

Develop, maintain and manage an effective information management system for nursing practice 
SAQA US ID UNIT STANDARD TITLE
252086  Develop, maintain and manage an effective information management system for nursing practice 
ORIGINATOR
SGB Nursing 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 09 - Health Sciences and Social Services Promotive Health and Developmental Services 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 7  Level TBA: Pre-2009 was L7 
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 be useful for people working as clinically focused, service orientated, independent, registered staff nurses, who are able to render basic care to persons with stable and uncomplicated general health problems, as determined by the appropriate legislative framework.

This unit standard will recognise the essential knowledge and skills required to maintain and manage an effective information system for documenting nursing and health care delivery. It recognises competence to use data from a health information system for making decisions to provide and improve nursing practice. Competent persons will further facilitate and support the maintenance of an efficient health information system.

People credited with this unit standard are able to:
  • Demonstrate an understanding of health information systems.
  • Maintain a documentation system for nursing.
  • Use information and data to improve performance and quality of nursing.
  • Maintain privacy, confidentiality, legal and ethical requirements for a health information system. 

  • LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    The credit calculation is based on the assumption that learners are already competent in terms of the following outcomes or areas of learning when starting to learn towards this unit standard:
  • Nursing team roles and responsibilities.
  • Ethical and Legal Codes.
  • Computer skills.
  • Numeracy; Documentation and report writing. 

  • UNIT STANDARD RANGE 
    Specific range statements are provided in the body of the unit standard where they apply to particular specific outcomes or assessment criteria.

    The following scope and context applies to the whole unit standard:
  • The Nurse functions within the scope of practice of a staff nurse as formulated by the SANC and the Nursing Act. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Demonstrate an understanding of health information systems. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The different components of the health information systems are accurately identified and described in terms of their purpose, organisation and parameters. 

    ASSESSMENT CRITERION 2 
    Hardware and software components are identified and explained in terms of their purpose and function. 

    ASSESSMENT CRITERION 3 
    Different data sets are identified and correctly accessed in terms of specific information requirements. 
    ASSESSMENT CRITERION RANGE 
    Data sets include:
  • Patient information system; health indicator information system; health facilities information system.
     

  • ASSESSMENT CRITERION 4 
    The system is explained in terms of its application in health care and the ways in which the information enhances the quality of nursing care. 

    SPECIFIC OUTCOME 2 
    Maintain a documentation system for nursing. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Key requirements for the maintenance of an effective data system are identified and described in relation to own practice and responsibilities. 

    ASSESSMENT CRITERION 2 
    Completion of documentation is monitored for compliance with national and institutional policies and procedures. Non-compliance is identified and corrected. 

    ASSESSMENT CRITERION 3 
    Individual and facility records are entered accurately and promptly into the information system, in accordance with established procedures. Entries are coded as required by the classification system. 
    ASSESSMENT CRITERION RANGE 
    Individual records include:
  • Biographical details; treatment records; progress reports.

    Facility records include:
  • Admissions, discharges, bed occupancy rate, illnesses, treatment, medicines record; test results; acuity reports.
     

  • ASSESSMENT CRITERION 4 
    The use of clinical vocabularies and terminologies in the organization's health information systems is monitored to ensure consistency and accuracy in communication and data capture. The importance of correct use is explained with reference to external use of the records. 

    ASSESSMENT CRITERION 5 
    Health records are evaluated to ensure that the record supports the diagnosis and reflects the patient's progress, clinical findings, and discharge status. Information gaps are identified and rectified according to established procedures. 

    SPECIFIC OUTCOME 3 
    Use information and data to improve performance and quality of nursing. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Facility data is analysed and trends identified for planned and actual resource utilisation, together with factors responsible for the trend. Adjustments to allocations and schedules are justified in terms of the trends reflected. 
    ASSESSMENT CRITERION RANGE 
    Trends include:
  • Facilities, units, areas where people are working, including community.
     

  • ASSESSMENT CRITERION 2 
    Clinical data is analysed and trends identified for health issues, together with factors responsible for the trends. Actions in response to issues are appropriate in terms of the issue identified, and medical authority guidelines and protocols. 
    ASSESSMENT CRITERION RANGE 
    Trends include:
  • Disease profile, increased infection rates, length of stay; high infant mortality.
     

  • ASSESSMENT CRITERION 3 
    Decision making on health care is analysed for effectiveness and accuracy in terms of the supporting data. The analysis identifies weaknesses and provides an evidence base for improved future health care decisions. 

    ASSESSMENT CRITERION 4 
    Statistical analysis of health care related information provides clear indications on the cost effectiveness and quality of health care. 
    ASSESSMENT CRITERION RANGE 
    Statistical analysis includes:
  • Percentages, ratios, epidemiological formulas.
     

  • SPECIFIC OUTCOME 4 
    Maintain privacy, confidentiality, legal and ethical requirements for a health information system. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Legal and regulatory requirements related to health information systems are identified and implemented in accordance with the provisions in health related legislation and regulations. 
    ASSESSMENT CRITERION RANGE 
    Requirements include:
  • Disclosure of information; security of records; provisions for electronic records; duration of record keeping; disclosure of diagnoses/notifiable diseases.
     

  • ASSESSMENT CRITERION 2 
    Policies and procedures reflecting the institution's position on confidentiality are developed in conjunction with relevant experts, validated against legislation and regulations, and communicated to staff through appropriate channels. 

    ASSESSMENT CRITERION 3 
    Access to, and disclosure of, personal health information is managed in accordance with institutional policies and procedures, and the provisions of legislation governing access to information. 
    ASSESSMENT CRITERION RANGE 
    Legislation includes:
  • Access to Information Act; National Health Act; Nursing regulations; Electronic Information Control Act; Administrative Justice Act; Constitution.
     

  • ASSESSMENT CRITERION 4 
    The importance of sharing personal health information within the professional team treating the patient is explained with reference to holistic health care, and continuity of care. 

    ASSESSMENT CRITERION 5 
    Breaches of confidentiality are managed in terms of the established policies and procedures, in a manner that protects the interests of the individual and institution. 

    ASSESSMENT CRITERION 6 
    The management of information, and disclosure of information, is consistent with accepted and agreed ethical standards of practice. 
    ASSESSMENT CRITERION RANGE 
    Standards include:
  • Professional code of practice for nurses; institution code of practice; breach of confidentiality; informed consent; disclosure without consent.
     


  • UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    Accreditation Options:
  • Providers of learning towards this unit standard will need to meet the accreditation requirements of the relevant ETQA.

    Moderation Option:
  • The moderation requirements of the relevant ETQA must be met in order to award credit to learners for this unit standard. 

  • UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    The following essential embedded knowledge will be assessed through assessment of the specific outcomes in terms of the stipulated assessment criteria. Candidates are unlikely to achieve all the specific outcomes, to the standards described in the assessment criteria, without knowledge of the listed embedded knowledge. This means that for the most part, the possession or lack of the knowledge can be directly inferred from the quality of the candidate's performance. Where direct assessment of knowledge is required, assessment criteria have been included in the body of the unit standard:
  • Definition, elements & components of health information system.
  • Analytic and interpretive statistics required for analysis of information.
  • Report writing. 

  • UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    Identify and solve problems and make decisions using critical and creative thinking.

    Note: Essential in establishing an information system; and in the use of the system. 

    UNIT STANDARD CCFO WORKING 
    Work effectively with others as members of a team, group, organisation or community.

    Note: Health care is team based. 

    UNIT STANDARD CCFO ORGANISING 
    Organise and manage themselves and their activities responsibly and effectively.

    Note: Core to the standard: The system organises information. 

    UNIT STANDARD CCFO COLLECTING 
    Collect, analyse, organise and critically evaluate information.

    Note: Core to the standard: The system stores data. 

    UNIT STANDARD CCFO COMMUNICATING 
    Communicate effectively, using visual, mathematical and/or language skills in the modes of oral and/or written presentations.

    Note: Core to the standard: The system organises information for use in a variety of ways. 

    UNIT STANDARD CCFO SCIENCE 
    Use science and technology effectively and critically showing responsibility towards the environment and health of others.

    Note: Core to the standard: Electronic (or paper based) system to organise information. 

    UNIT STANDARD CCFO DEMONSTRATING 
    Demonstrate an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation.

    Note: Core to the standard: The system organises information and enables it to be accessed in different combinations in order to understand trends in health care. 

    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 
    Notes to Assessors:

    Assessors should keep the following general principles in mind when designing and conducting assessments against this unit standard:
  • Focus the assessment activities on gathering evidence in terms of the main outcome expressed in the title to ensure assessment is integrated rather than fragmented. Remember we want to declare the person competent in terms of the title. Where assessment at title level is unmanageable, then focus assessment around each specific outcome, or groups of specific outcomes.
  • Make sure that evidence is gathered across the entire range, wherever it applies. Assessment activities should be as close to the real performance as possible, and where simulations or role-plays are used, there should be supporting evidence to show the candidate is able to perform in the real situation.
  • Do not focus the assessment activities on each assessment criterion. Rather make sure the assessment activities focus on outcomes and are sufficient to enable evidence to be gathered around all the assessment criteria.
  • The assessment criteria provide the specifications against which assessment judgements should be made. In most cases, knowledge can be inferred from the quality of the performances, but in other cases, knowledge and understanding will have to be tested through questioning techniques. Where this is required, there will be assessment criteria to specify the standard required.
  • The task of the assessor is to gather sufficient evidence, of the prescribed type and quality, as specified in this unit standard, that the candidate can achieve the outcomes again and again and again. This means assessors will have to judge how many repeat performances are required before they believe the performance is reproducible.
  • All assessments should be conducted in line with the following well documented principles of assessment: appropriateness, fairness, manageability, integration into work or learning, validity, direct, authentic, sufficient, systematic, open and consistent.

    The following particular issues should be taken into consideration when assessing against this unit standard:
  • The SANC guidelines are used as a reference for integrated assessment.
  • Formative Assessment: A variety of assessment strategies and/or approaches integrating theory and practice must be used. These could be tests, assignments, projects, demonstrations or clinical assessments or any other applicable method.
  • Summative: This could take a form of oral, written and/or practical assessments as agreed to with the relevant ETQA.

    Definition of Terms:

    Terms have been clarified as far as possible through the use of range statements. Further clarification of terms is provided as follows:
  • None. 

  • QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Core  59257   Bachelor of Nursing  Level 7  NQF Level 08  Reregistered  2023-06-30  As per Learning Programmes recorded against this Qual 
    Elective  59236   National Diploma: Nursing  Level 5  NQF Level 05  Passed the End Date -
    Status was "Reregistered" 
    2020-07-30  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.