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Clinical Record Keeping: A Hands-On Approach

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

This page will discuss the ONLINE course.

Courses are approved for Continuing Education Accreditation, click HERE to see the CE units.

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The purpose of this course is to give hands–on healthcare practitioners a deeper understanding of clinical record keeping — and the tools to do it right.
Using a mix of theory, samples, tips and real–life cases, this course will inspire and equip you to improve the quality of your clinical notes.
Whether you want to survive an audit, build a new practice or streamline a busy one, better record keeping will boost your confidence because you will know that you've covered all the bases. If you want to stake out your territory in the health care arena by communicating more effectively with your patients and other healthcare providers — good record keeping lets you do this, too.
The quality of patient files is not just a side–note of a health care practice — it is foundational to your success.


This course is a comprehensive look at why and how to keep clinical records that enhance safety and opportunities for both patients and practitioners.
Whether we use off–the–shelf or customized forms, be they paper or electronic, the choice of forms we use matters — a lot! This course explores each of the forms that can be found in the patient's file — standard features (what and why) and how to customize them.
Within the topic of each 'form', the course material emphasizes the four goals of record keeping.

This course consists of 12 chapters to be completed at the learner's own pace. The instructional material is supplemented with practical exercises and links to online resources.
At the end there is a comprehensive mail–in test. A successful score (75%) will earn a certificate of completion and applicable Continuing Education Credits. One rewrite is permitted.

Course List
  1. Why Keep Clinical Records?
  2. Intake Forms
  3. Special Intake Forms — Pain Assessment Tools, Functional Assessment Tools and Motor Vehicle/Personal Injury Intake Forms
  4. History Form
  5. Interviewing Skills
  6. Physical Examination Form
  7. Clinical Impression / Treatment Plan
  8. Truly Informed Consent
  9. Ongoing Treatment Records
  10. Reports / Written Communications
  11. Legal Issues
  12. Clinical Record Keeping and Practice Management

Chapter 1   Why Keep Records?

As healthcare providers, we would all like to believe we deliver a particular type of care that really works. And that we do a good job of it. Perhaps we even believe we do a great job caring for those who are suffering, helping them to restore and maintain function which has been lost to injury or disease.

But how do you know for sure you're actually doing a good job and using methods which make a positive difference? And, more importantly, how can anyone else make that determination?

Our thoughts and our intentions can only be judged by our actions. The way we move and the words we speak are transitory things — they are here and gone, but written records are forever (or 16 years, whichever comes first!).

Patient records are the only evidence of your skills of observation and communication. They are the only proof that you are providing the care your patients need.

In this section on the 'whys' of clinical record keeping, we will be examining safety, quality assurance and evidence based care from the perspective of all interested parties.
     1st party — the patient
     2nd party — the practitioners
     3rd party — regulatory bodies and insurance companies and lawyers

— Patient safety as the primary mandate
— Establishing a baseline
— Figuring out what's going on
— Opportunities for patient education and research
— Professionalism and high standards
— Strategies and technologies for gathering/documenting information
— Legibility and abbreviations

Learning Objectives: — Appreciate the challenges that record keeping presents the profession
— Reflect on the assets of good patient records
— Consider the merits of electronic records
— Understand that it's all about using the right forms

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Chapter 2   Intake Forms

The intake form could be described as one of the 'history twins'.
It is the subjective, historical information as documented by the patient and it is an integral partner to the history form which the practitioner fills out.
It helps us gather clues to the mystery that is our patient so we can better understand the breadth of their needs and the depths of their suffering.
When it comes to building a Health Care practice, the new patient intake forms you choose to use is one of the most important decisions you will make. It has more impact on your success and your reputation than (almost) any other piece of paper in the file so it is well worth it to look more closely at your options.

— Goals of using a good intake form
— How to ask important questions
— Features of all standard intake forms
— Regularly updating contact information
— Tips for customizing and practice building

Learning Objectives:
— Analyze New Patient intake forms as to their usefulness in collecting the right kind of information for your practice
— Customize an intake form with features which will build your practice
— List four goals which are accomplished with the use of a well-constructed intake form
— Devise a system for regularly updating contact information
— Identify contraindications to care based on information provided on the intake form

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Chapter 3   Special Intake Forms — Pain Assessment Tools, Functional Assessment Tools and Motor Vehicle/Personal Injury Intake Forms

When a patient presents with pain or disability, or if they have been involved in an accident, there are special intake forms which can be utilized. The purpose of using these 'Patient Based' tools is to quantify and record the facts of their case when they first present for care and to track their progress over time.

— What are 'Special' intake forms and when should they be used?
— Patient Based Outcomes Assessment Instruments
— Visual Analog Scales, Likert Scales, Questionnaires
— Pain and function questions for all new patients
— How to use these special tools to evaluate pain and disability
— Special questionnaires for motor vehicle/personal injury cases

Learning Objectives:
— Explain the value of using PBOAI's for patients who have pain and disability
— Recognize cases where these special forms will provide valuable information for patient management and know how to use them properly
— List five features of a patient's pain which are regarded as potentially ominous
— List five constitutional symptoms which can accompany pain that you need to be on the lookout for
— List the three most common causes of physical disability
— Define what is meant by minimum detectable clinical change and explain how it relates to the scale width used on the form
— Name five examples of Patient Based Outcomes Assessment Instruments which are widely used for assessing function

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Chapter 4   History Form

A carefully gathered patient history will uncover important details of the story of their suffering. Like all good stories, we want to know the 'who, where, what, when, why and how'. We need to know what's going on and we'll need to take notes.

A good clinical history will inform your decisions about taking on their case, establish a baseline for future comparison, guide your choice of physical examination procedures and influence the treatment approach you employ.

— Is the problem functional or pathological?
— Mnemonics for the required features of the history of a chief complaint
— The features of a chief complaint (10) — what does it all mean?
— Components of a comprehensive health history
— Red flags in the history that suggest pathology
— How to make your own history form
— What if a patient has no chief complaint? Find one!

Learning Objectives:
— Use an effective mnemonic device to ensure collection of all necessary details of a patient's chief complaint
— Conduct a comprehensive health history which includes family history, systems review, medical history, lifestyle and other treatments
— Distinguish 'functional' from 'pathological' as revealed by the details of their history
— Make logical decisions about which physical examination tests to perform based on the details of their history
— Create a history form which ensures you fill in all the blanks in their story
— List seven features of the history of a chief complaint which are red flags
— Generate a tangible chief complaint for all patients
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Chapter 5   Interviewing Skills

This chapter is about methods and strategies which will allow for a health interview to flow organically. Like guiding a canoe down a winding, branching river, you will learn to navigate the right lines of questioning, letting your patient tell their story in a way that suits them.

— Why take notes?
— Strategies for conducting a good interview
— Clinical reasoning on the fly
— Red flags

Learning Objectives:
— Explain and demonstrate the difference between open and closed–ended questions and be able to use both strategies as needed
— Create an environment which is conducive to a patient–focused conversation

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Chapter 6   Physical Examination Form

Why is the physical examination so important?
Rule number one — it is the law. At minimum, the area of chief complaint must be physically examined.

Why write it down?
How else will you prove that you obeyed Rule #1??

This chapter examines what must be done and why and how to document your findings in the most efficient way possible.

— Features of objective testing
— Basic requirements of the physical examination
— Principles of charting observations/palpation/special tests/vitals
— ROM charting using Maigne diagrams
— Devising a physical examination form that's comprehensive and easy to use
— Contra–indications to care
— Requesting more information

Learning Objectives:
— Devise a form which lets you document pertinent findings consistently
— Construct a ROM chart for any joint and explain what is meant by 'degrees of freedom'
— Chart ROM limitations using a standard format
— Explain the reasons for doing passive and resisted ROM's and use a consistent system for charting your findings
— Describe how orthopedic tests work
— Understand what it means to designate a finding as positive or negative and the importance of documenting both
— Define the difference between the approaches to absolute and relative contraindications to care

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Chapter 7   Clinical Impression / Treatment Plan

With every new patient (and regular patients with a new problem) you must be able to answer some questions.
Your patient needs to know what's wrong in language they can understand. They need to know what you will do to help them and how long it will take.
Can they expect to be 'cured'? Is there something they can do to prevent this from coming back? As a healthcare professional you are expected to have good answers for them.

— Assessment vs Clinical Impression vs Diagnosis
— General requirements of a clinical impression
— Prognosticating
— Essential features of a treatment plan
— Report of findings — oral and written

Learning Objectives:
— Formulate a clear, concise clinical impression based on history and physical exam findings
— Prognosticate based on assessment findings so as to set realistic expectations of results and the need for future care
— Create a treatment plan based on the clinical impression and prognosis
— List five features of a good treatment plan
— Appreciate the value of a written Report of Findings for patient education and communicating with other health care professionals

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Chapter 8   Truly Informed Consent

Health care has its risks. Some procedures are worth it, some are not.
Who decides? And, how much information does a patient need in order to make good decisions about their own health? That is the subject of this chapter.

— Who can consent?
— Under what conditions can they/ must they consent?
— What are they consenting to — 7 features of truly informing
— Rules of giving consent
— Material risks and remote risks and the duty to inform

Learning Objectives:
— Define 'material' risk and understand the duty to inform your patients
— List seven points of the information a practitioner gives a patient in order for them to be truly informed and explain briefly why each is important
— Review provincial legislation on guidelines around 'Consent to Health Care' and summarize the conditions under which truly informed consent can be given

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Chapter 9   Ongoing Treatment Records

Ongoing treatment records are, in many ways, the most important part of the patient's file, yet they are the most often neglected. This chapter looks at developing better habits around the records that you keep every day.

— What are SOAP notes?
— What information must be included for each visit
— Importance of being specific about the details
— Customizing OTR form — shortcuts and add–ons
— Three questions to ask everyone — spot the red flags
— Functional screening tests
— Reassessments — What to do and when to do it

Learning Objectives:
— Produce clear SOAP notes for a treatment session
— Clearly define and give examples of the information collected under each heading
— Generate a chief complaint and physical examination findings for every patient using screening procedures
— Document a mini–history for a chief complaint
— Create your own OTR form
— Spot the deficiencies in sample OTR's
— Produce a 'Reassessment Findings Summary'

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Chapter 10   Reports / Written Communications

Whenever you fill out a form for an insurance company, or construct a narrative report or send a copy of your clinical notes to a lawyer or another healthcare practitioner, you are making an impression — for better or worse.

Written communications — referral letters and reports and brochures — give us the perfect tool to shape the narrative of our public image and stake out our territory in the healthcare arena. Engaging in writing about your patients and your profession will also make you a better practitioner because you'll be more attentive to both the details and the bigger picture. This is one of the best ways to build your career as a valuable member of the healthcare community.

In this section we will be exploring how you can use written communications to both shine a positive light on what you do and promote more inter–professional cooperation, with the ultimate goal of providing high quality, patient–centered care.

— Importance of written communications in health care practice
— Types of reports
— Special requirements of medico–legal reports
— When to generate reports
— Patient confidentiality, permission to release/request information
— Preparing reports/treatment plans for insurance companies

Learning Objectives:
— Summarize a patient's case in a one page report for a third party
— Compare and contrast the format of a report to the format of daily SOAP notes
— Have measures in place to guarantee patient confidentiality

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Chapter 11   Legal Issues

Relationships are complicated and none more so than that between a healthcare provider and their patient. One of them is suffering, the other has the capacity to help them or hurt them. And, money changes hands.
What could possibly go wrong?

Laws are made by governments. Bylaws, regulations and codes of conduct are set out by college regulators, boards and associations. These are social constructs intended to protect public safety and professional integrity.

This chapter looks at legal issues from the perspective of 'patient rights'.

— Patients' rights in health care
— Duty to protect patient's privacy
— Implied and explicit consent
— Keeping files secure and accessible
— File retention / disposal rules
— Terminating the practitioner–patient relationship
— Codes of ethics
— Duty to report

Learning Objectives:
— Retain a patient's file securely
— Provide files/information for transfer as requested by the patient or a third party
— List five basic rights that patients have
— Respond appropriately to the loss or theft or patient records
— Terminate patient care — legally and professionally
— Outline the circumstances of a 'duty to report'
— Apply a clear code of ethics in your practice

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Chapter 12   Clinical Record Keeping and Practice Management

This is a review of what makes a patient file 'adequate' and a summary of some practical strategies for accomplishing your goal of keeping better notes, as seen through the lens of building and managing your practice.

— Review all forms for their usefulness in educating patients
— How clinical records are assessed for adequacy
— Evidence based care
— Six steps to improve your self–esteem and professional reputation
— Electronic health records
— Checklist for file self–review

Learning Objectives:
— Choose/create the right forms for each part of a comprehensive patient file
— Efficiently keep records that are consistent, contemporaneous and effective by using the right forms
— List 5 attributes of good records
— List 4 goals of Clinical Record Keeping
— Assess the adequacy of your patient records
— Research different providers of software for Electronic Records, comparing utility/ price/ compliance with privacy protection

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