Medical Record Keeping

This course is scheduled for multiple dates: November 15, January 31, February 6 and April 25, 2025.

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.

Learning 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

CME Accreditation: 
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).