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.

Course Schedule - Workshop

Registration

This course is offered ONLINE multiple times per year.

Workshops are usually held on Friday afternoons. 

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: $650 

Contact

Marcela Reyes, Program Assistant
marcela.reyes@ucalgary.ca

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

Course Format

Participants will complete a series of learning activities:

  • Online self-learning pre-workshop activity
  • Workshop
  • Online post-workshop activity
  • Webinar

 

 

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

 

Faculty and Planning Committee

Faculty

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

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 

Nothing to disclose