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. ROBLEDA FONT, Gemma - grobleda@uic.es

The student will focus on the appointments by email.

Introduction

The recording of information in the medical record is a fundamental element for monitoring the evolution of patients and for ensuring effective communication among the various professionals involved in their care. Furthermore, it is a key tool for making nursing work visible and objective, enabling outcome evaluation and promoting the generation of knowledge applicable to research and the continuous improvement of clinical practice.

In an increasingly digitalized healthcare context, new technologies offer the opportunity to record care data electronically. This requires future nursing professionals to develop the skills necessary to document the entire nursing care process using the available digital platforms, while maintaining clarity, coherence, and content quality, and always respecting the current legal and ethical framework.

Pre-course requirements

  • Learning willingness.
  • Teamwork skills.
The Department of Nursing in the Faculty of Medicine and Health Sciences has agreed that it is compulsory for all students taking a Bachelor's degree in Nursing, when participating in online classes, to turn on their camera and remain visible to lecturers and professors at all times.

If there are students in self-isolation due to the COVID-19 health and safety measures, who cannot physically attend class at the University like their peers, teaching staff will carry out online teaching during this isolation period only so that the student(s) in question can attend their classes online. The rest of the students will have to attend their classes in person in the classroom.

 

Objectives

  1. Write clinical records with accuracy and legal compliance.

  2. Apply structured handover techniques such as SBAR/ISBAR.

  3. Analyze the legal and ethical implications of clinical documentation.

  4. Work with simulated scenarios and integration of technologies such as artificial intelligence.

  5. Develop effective clinical communication skills.

Competences/Learning outcomes of the degree programme

  • 11. E - Establish effective communication with patients, families, social groups and partners and promote health education.
  • 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

The student will be able to:

  • Write clinical records using clear scientific language. (Apply)

  • Effectively apply SBAR/ISBAR techniques. (Apply)

  • Edit and review records using artificial intelligence. (Analyze / Evaluate)

  • Simulate handovers and clinical documentation in complex cases. (Apply / Evaluate)

  • Design comprehensive reports integrating legal and ethical aspects. (Create)

Syllabus

  • Importance, functions, and quality of clinical records

  • Medical record and clinical pathways, structure

  • Effective communication and handovers

  • Discharge report

  • Legal and ethical aspects

  • Practical and simulated application of records and handovers

  • Analysis of inadequate practices

Teaching and learning activities

In person



Type of activity Methodological descriptionWorkload (hours)
Plenary sessions (on-site) Plenary sessions are the space to work on the theoretical content of the course using various strategies: participatory lectures, practical documentation activities, discussions, case analysis, and student presentations. 24 h
Simulations (on-site) Students will work on two simulated cases in the simulation lab, applying the knowledge developed during plenary sessions and seminars. 2 h
Independent work (remote) - Preparation of mini-project content. - Preparation of audio materials and presentations. - Reading recommended texts. - Watching and analyzing videos. 49 h

Evaluation systems and criteria

In person



Type of activity

Learning level (Bloom’s Taxonomy)

Weight in final grade

Mini-project Apply knowledge to produce accurate and legally compliant clinical records. (Apply – Bloom 3) Analyze errors and best practices in clinical documentation. (Analyze – Bloom 4) Create discharge reports and nursing progress notes with AI support. (Create – Bloom 6) Communicate effectively in multidisciplinary clinical settings. (Apply – Bloom 3) 40%
Active participation and classroom activities on clinical records Apply knowledge to produce accurate and legally compliant clinical records. (Apply – Bloom 3) Analyze errors and best practices in clinical documentation. (Analyze – Bloom 4) Create discharge reports and nursing progress notes with AI support. (Create – Bloom 6) 40%
Simulation Communicate effectively in multidisciplinary clinical settings. (Apply – Bloom 3) 10%
Digital Escape Room Analyze errors and best practices in clinical documentation. (Analyze – Bloom 4) 5%
TV series Evaluate the ethical implications of clinical records. (Evaluate – Bloom 5) 5%

Passing requirement:
A minimum average grade of 5 must be obtained in both the mini-project blocks and the classroom activity block in order to average with the rest of the course components.

Resit / Recovery assessment:
In case of failing the course, the recovery will consist of:

  • Individual written exam on the course-related content.

  • Individual oral exam including a brief clinical case presentation and resolution of a handover.

Justified absences from evaluable activities
General Regulations – Nursing Degree
Only the following reasons will be accepted as justified absences:

  • Serious illness of the student (with a medical report stating the impossibility of attending academic activities).

  • Death of a first-degree relative: parents, siblings, or children.

  • Judicial summons.
    Justifications must be signed and stamped by the corresponding authority.

Medical appointment certificates will not be accepted under any circumstances.

NOTE: Simulation is an evaluable activity that cannot be resat. If a justified absence occurs on the day of the simulation, the recovery activity will be based on a clinical case.

First Class Honours will not be awarded in the resit.

Honor Matrix Assignment Procedure (MH)

  1. The criterion for assigning Honorary Enrolments (MH) is based on the Excellent (9.0).
  2. The assignment is solely for the teacher and does not have to give it, even if the student has obtained a mark above 9.0.
  3. In case the teacher decides to award MH, he will not take into account the numerical mark and the highest, but will evaluate other factors. The HM might not match the highest numeric score.

Procedure for Non-presented Assignment (NP)

  1. To register an NP in the student's file, it must not have been submitted to any of the evaluation tests throughout the assignment.
  2. If a student has submitted to one of the evaluation tests, the corresponding percentages in the teaching guide will be applied, with a 0 in those not presented.

Procedure for plagiarism or academic fraud

Any assignment or activity (including exams) in which plagiarism, falsification or academic fraud is detected, will result in a failure of the activity and an academic sanction that will entail from the loss of enrolment rights in this subject, to the opening of a file process.

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 14/11/2025 10:00h
  • E2 25/06/2026 10:00h
Print version