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 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.
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. 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 rationale for nursing records.
  • Importance of communication and transfer of information.
  • Quality criteria of the records.
  • Clinical History
  • Ethical and legal aspects related to the recording of information.
  • Discharge Report
  • Recording the Nursing Care Process

Teaching and learning activities

In person



  • Masterclass.
  • Team work.
  • Cases study.

 

Evaluation systems and criteria

In person



  • Partial exam (20%)

  • Classroom activities (30%)

  • Final exam: theoretical and practical (50%).

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

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 18/11/2024 10:00h
  • E2 18/06/2025 08:00h
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