Education Services

Helping Hands–On Health Care Professionals
Achieve Excellence

Clinical Record Keeping: A Hands-On Approach

There are two versions of the course: In–Person and Online.

This page will discuss the IN–PERSON course.

In–Person courses have been temporarily suspended.

The next available In–Person courses are:
Courses are in the process of being organized. We will post them as soon as they are ready!

Read what others, who have taken the courses, have thought of them here

You can now use our easy online REGISTRATION to start your courses.




This 6 hour course is a comprehensive look at why and how to keep clinical records which enhance both safety and opportunities for patients and practitioners.

Whether we use standard or customized forms (be they paper or electronic), it matters how they are formatted and it matters that we develop consistent habits for using them.

Within the context of each of the half dozen forms found in a patient's file, the course material emphasizes the four goals of record keeping.

  1. Identify red flags
  2. Establish a baseline
  3. Understand the patient's problem
  4. Create opportunities for patient education, practice building and research


Classroom Strategies


Course Outline

  1. Why keep records, Intake forms
  2. History form
  3. Physical examination form
  4. Clinical impression, treatment plan, informed consent
  5. Ongoing treatment records, reassessments
  6. Legalities


Approximately one hour is spent on each of these general topics.

Each hour is about 40 minutes informational (lecture, notes, samples, flipchart) and 20 minutes for activities.

Learning Objectives

By the end of this six hour course, the learners will be able to:

  1. Analyze intake forms as to their usefulness in collecting the right kind of information
  2. Ask questions effectively using leading and open-ended methods
  3. Decide which aspects of the physical examination are most useful for the learner and their patients
  4. Follow best practices for documenting physical findings
  5. Estimate ranges of motion and document them accurately
  6. Develop a system for regularly updating contact information
  7. Produce clear SOAP notes for ongoing treatment records
  8. Summarize a patient's case in a one page report for the patient or another practitioner
  9. Appreciate the practice building opportunities of customized office paperwork
  10. Formulate a clear, concise clinical impression based on information gathered with intake/history/physical exam and reports
  11. Prognosticate based on findings to set up an expectation of results and the need for future care
  12. Create a realistic treatment plan based on clinical impression and prognosis
  13. Identify contra-indications to care (absolute and relative) and know when/how to decline services
  14. Know how to efficiently keep records that are consistent, comprehensive and effective
  15. Appreciate the legal aspects of file management