Medical Record Keeping

Medical Record Keeping

Course Overview

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.

Brochure

Current Offerings

*All the steps are REQUIRED for course completion and to receive credits*

Upcoming workshop dates:

Cohort 4 - March 14 - June 19,  2025

Online Session (required to attend both sessions)                                                             
                                                                     Date                       Time                 Pre-requisites to Attend the session
• Online Workshop (Live)                            March 14, 2025     1 - 4 pm MT      completed modules 1-6 
• Online Post Workshop Webinar (live)     June 19, 2025        6 - 7 pm MT     completed modules 7-9 and attended the online workshop
Please contact monica.rast@ucalgary.ca to be notified when registration opens up

 

Cohort 5 - June 13 - September 11,  2025

Online Session (required to attend both sessions)                                                             
                                                                      Date                                Time                 Pre-requisites to Attend the session
• Online Workshop (Live)                            June 13, 2025                 1 - 4 pm MT      completed modules 1-6 
• Online Post Workshop Webinar (live)     September 11, 2025        6 - 7 pm MT     completed modules 7-9 and attended the online workshop
Please contact monica.rast@ucalgary.ca to be notified when registration opens up

Registration

This course is offered ONLINE multiple times per year.

Workshops are held on Fridays from 1-4pm, and webinars are held on Thursdays from 6-7pm.

Following confirmation of your registration, you will receive instructions on how to access the online self-learning pre-workshop activity, which is available for you to complete at any time prior to the workshop.

Course fee: $799 + GST

This blended course contains self-paced online learning and live group learning. A written refund request may be submitted to ecme@ucalgary.ca within 72 hours of registering for the course. $75 will be retained for administrative costs and online content provision will be disabled (if applicable). Terms and conditions may apply to this refund policy. Refunds are not available 72 hours after registration.

Contact

Monica Rast, Education Coordinator

Email

Course Objectives

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

Credits

CFPC
COURSE GROUP ACTIVITY
MAINPRO+ GROUP LEARNING

This three-credit-per-hour Group Learning program meets the certification criteria of The College of Family Physicians of Canada and has been certified by the University of Calgary Office of Continuing Medical Education and Professional Development for up to 30.0 Mainpro+ credits.

RCPSC
MOC SECTION 3 SELF-ASSESSMENT PROGRAM

This activity is an Accredited Self-Assessment Program (Section 3) as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada, and approved by University of Calgary Office of Continuing Medical Education and Professional Development. You may claim a maximum of 10.0 hours (credits are automatically calculated).

Course Format

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.

 

Faculty and Planning Committee

Faculty

Nothing to disclose

Nothing to disclose

Nothing to disclose

Planning Committee

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

Assistant Registrar and Complaints Director, College of Physicians and Surgeons of Alberta 

Nothing to disclose

Clinical Assistant Professor, Section Chief Community Primary Care, Department of Family Medicine – Calgary Zone 

Nothing to disclose

Senior Medical Advisor, College of Physicians and Surgeons of Alberta 

Nothing to disclose

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

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

Senior Medical Advisor, College of Physicians and Surgeons of Alberta

Nothing to disclose