Medical Record Keeping

The medical record facilitates good care. With contemporaneous documentation of patient encounters, the reflection and review can reinforce the consistency, completeness and quality of your clinical activities. This program aims to address sufficient documentation, which is central to patient safety and continuity of quality care. Participants will learn how to appropriately document patient encounters following the Subjective Objective Assessment Plan (SOAP) format.

Physicians who have the need or desire to improve their medical documentation.

Currently the course program is most relevant to primary care and general practice.

At the end of this course, learners will be equipped to:

• Recognize the general principles and multiple purposes of medical record documentation
• Identify the elements and characteristics of appropriate documentation of patient encounters
• Use the SOAP-based tool to self-evaluate and improve the practice of documenting patient encounters
• Practice effective written communication of referral or consult letters

Participants will complete a series of learning activities:

• Online self-learning pre-workshop activity (modules 1-6)
• Online live Workshop (3 hours)
• Online post-workshop activity (modules 7-9)
• Online live post-workshop webinar (1 hour)

Completion of the online self-learning activity is the prerequisite for attending the workshop and the webinar.

Heather Armson MD MCE CCFP FCFP Course Chair
Executive Director, Foundations for Medical Practice Education, Assistant Dean, Personalized Learning, Office of Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary
Disclosure: Research Director for The Foundations for Medical Practice Education | Received research grant for The Foundations for Medical Practice Education

Michael Caffaro MD CCFP
Assistant Registrar and Complaints Director, College of Physicians and Surgeons of Alberta 
Nothing to disclose

Monica Sargious MD CCFP
Clinical Assistant Professor, Section Chief Community Primary Care, Department of Family Medicine – Calgary Zone 
Nothing to disclose

Nigel Flook MD CCFP FCFP
Senior Medical Advisor, College of Physicians and Surgeons of Alberta 
Nothing to disclose

Sarah Weeks MD MEHP FRCPC
Associate Clinical Professor, Department of Cardiac Sciences and Medicine, Libin Cardiovascular Institute of Alberta; Assistant Dean Pre-Clerkship, Undergraduate Medical Education, University of Calgary
Nothing to disclose

Utkarsh Subnis MSc(Med Ed), PhD(c) - CME&PD Representative
Education Consultant, Office of Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary
Disclosure: Direct financial payments, gifts, in-kind compensation or honoraria: HAnalytics Solutions Inc. | Employee (Role: Sr. Medical Science Liaison); Fresh Squeezed Ideas Inc | Employee (Role: Sr. Innovation Strategist); University of Calgary employee