What happens after an assessment

Medical record keeping for physicians course

The Medical Record Keeping for Physicians course is an interactive four-hour workshop designed to support physicians in maintaining appropriate documentation in patient charts. Case-based examples and simulated patient encounters are used to demonstrate the practice of effective clinical record keeping. Course content was developed by practising physicians and with information from various stakeholders.

At the end of the course, attendees will:

• recognize the regulatory requirements of the medical record (CMPA, Medical Services Commission and College)
• have discussed the different types of physician-patient encounters and document appropriately
• have identified and incorporated innovative changes to their medical record keeping
• have demonstrated knowledge and understanding of what a good medical record entails

Chart submission guidelines and instructions are also provided after the course to bolster improvements and lead to a successful chart submission. We may require chart submissions for review to demonstrate that the required changes have been made.

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