Universitat Internacional de Catalunya - Barcelona

Advanced Clinical Records

• code 09819
• course 4
• term Semester 1
• type op
• credits 3

Module: Module MINORS (Choose one minor)

Matter: Advanced Clinical Care

Not specified

Head instructor

Office hours

The student will focus on the appointments by email.

 

Teacher of the matter:

 

Silvia Pilar spilar@csc.uic.es

Date of renovation of the Teaching Guide: May 2012

The information recorded in the patient's medical history is essential for monitoring the evolution of the patient and communication with other professionals involved in their care. At the same time serves to objectify our work as nurses for the evaluation results can then be used for research, creating future interventions for nurses.

As new technologies allow us to record data in a computerized future professionals must be able to capture the total content of the process of nursing care to platforms designed for such use without losing the essence of the message transmit or leaving the framework of the law

• Provision for learning.
• Capacity for teamwork.
• Attendance at 90% of classes.

1. Be able to make records based on clinical assessment of patients using scientific language, basing their actions and evaluating their interventions.
2. Be able to draw recommendations directed to the user to restore or maintain health.
3. Will use the software to record all data and to design the process of nursing care of patients.
4. Be aware of the importance of registering such written notice of their actions.

• 22. G - Use and management of information and research
• 23. B - Ability to analyze and synthesize.
• 26. G - Ability to generate knowledge from practice.
• 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.

• Is able to make records of their actions with a clear scientific language and to other professionals.
• Is able to capture so computerized assessment, and records the process of nursing care.
• Is aware of the legal implications of all their clinical records.

• · Conceptual framework and justification of nursing records.
• · Transmission of information.
• · Registration Process * Nursing Care.
• · Ethical issues related to the registration information.
• · Legal framework.
• · Manage software gazelle for nursing records.

• . Sessions exposure class.
• · Work in groups.
• · Carrying case.
  

The methodology is the same for the part of computer records, but with smaller working groups.