Universitat Internacional de Catalunya

Advanced Clinical Records

Advanced Clinical Records
3
9819
4
First semester
op
Module MINORS (Choose one minor)
Advanced Clinical Care
Main language of instruction: Spanish

Other languages of instruction: Catalan,

Teaching staff


Dra. MARTÍN FERRERES, María Luisa - marisamf@uic.es

The student will focus on the appointments by email.

Introduction

In the event that the health authorities announce a new period of confinement due to the evolution of the health crisis caused by COVID-19, the teaching staff will promptly communicate how this may effect the teaching methodologies and activities as well as the assessment.


The information of the medical records of the patient is essential to monitor the patient's progress and to enable communication with other professionals involved in the patient's care. At the same time it can be used to objectify our nurse work as well as to assess results that can later be used for research, providing quality to future nursing interventions.

Since new technologies allow us to computerize data, future professionals should be able to capture the entire contents of the process of nursing care into platforms designed for such use without losing the essence of the message to transmit nor getting out of framework of the current legislation.

Pre-course requirements

  • Learning willingness.
  • Teamwork skills.

Objectives

  1. Students will be able to conduct clinical records based on patient assessment using scientific language and assessing their interventions.
  2. Students will be able to develop recommendations for users to restore or maintain their health.
  3. Students will use the software to record all data and to design the nursing care process of the patient.
  4. Students will be aware of the legal importance of written records of their actions.

Competences/Learning outcomes of the degree programme

  • 11. E - Establish effective communication with patients, families, social groups and partners and promote health education.
  • 15. B - Work with the team of professionals as a basic unit in which uni or multidisciplinary and interdisciplinary professionals and other staff of health care are organized.
  • 16. G - Know the health information systems.
  • 21. B - Oral and written communication.
  • 22. G - Use and management of information and research
  • 23. B - Ability to analyze and synthesize.
  • 26. G - Ability to generate knowledge from practice.

Learning outcomes of the subject

  • Students are able to save records of their actions with a scientific and clear language for the rest of the professionals.
  • Students are able to computerize records, assessments and the process of nursing care.
  • Students are aware of the legal implications of all their clinical records.

Syllabus

  • Conceptual framework and justification of nursing records.
  • Flow of information.
  • Nursing care process register.
  • Ethical issues related to information record.
  • Legal framework.

Teaching and learning activities

In person



  • Masterclass.
  • Team work.
  • Cases study.

 

Evaluation systems and criteria

In person



  • Midterm exam: teory and practice (40%). 
  • Final exam: teory and practice (60%).

The final exam must to be approved to average both marks .

First Class Honours will not be awarded in first resit.

Bibliography and resources

Notes from the field.

Recommended bibliography for the teacher. 

 

Evaluation period

E: exam date | R: revision date | 1: first session | 2: second session:
  • E1 23/11/2020 12:00h
  • R1 14/12/2020 10:00h
  • E2 23/06/2021 12:00h
  • R2 02/07/2021 11:00h
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