Subject

Advanced Clinical Records

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

Main language of instruction: Spanish

Other languages of instruction: Catalan,

Timetable
 Sem.1  TU 12:00 14:00 
 Sem.1  WE 12:00 14:00 

Teaching staff

Head instructor

Dra. María Luisa MARTÍN - marisamf@uic.es

Office hours

The student will focus on the appointments by email.

Introduction

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.

Competencies

  • 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.

Learning outcomes

  • 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.
  • GACELA software management for nursing records.

Teaching and learning activities

  • Class presentation sessions.
  • Team work.
  • Cases study.

The methodology is the same for the computer records part, but with less team worm.

Evaluation systems and criteria

  • There will be a continuous assessment through activities and exercises that will count toward the final mark (40%). 
  • Final exam (60%).

Both parts have to be passed to average.

On first resit students will have to do a project to replace de continuous assessment.

First Class Honours will not be awarded in first resit.

Bibliography and resources

Notes from the field.

Recommended bibliography for the teacher. 

GACELA software.

Evaluation period

E: exam date | R: revision date | 1: first session | 2: second session:

  • E1 20/11/2019 12:00h
  • R1 16/12/2019 10:00h
  • E2 29/06/2020 12:00h
  • R2 03/07/2020 11:00h
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