AURORA

Education Services

Helping Hands-On Health Care Professionals
Achieve Excellence


Clinical Record Keeping: CRK 101 for Natural Health Practitioners

Course Description

The most important gift you can give your patients is your full attention.
Good record keeping helps you organize and document that attention, giving it form.

This course is about why and how to systematically and consistently record the facts of another person's health journey, with effective strategies to make your note taking better.

Constructing the right forms is the key to methodically taking note of useful information. With this, you will have a template for communicating more effectively with your patients and others in the healthcare community.

Course Outline

This course contains 6 PDF's with informative material, activities and quiz questions.

The topics covered include:

— Patient safety is # 1
— The most important information to take note of
— Solving problems and finding solutions
— Assessing progress and effectiveness
— Educating patients
— Collaborating with other healthcare providers

Table of Contents

PDF #1 Introductory notes Considerations and caveats

PDF #2 Four goals of record keeping :

— Identify red flags
— Establish a baseline
— Solve problems / find solutions
— Educate others

PDF#3 Four elements of record keeping SOAP notes essentials

PDF#4 Four tips for success

— Contemporaneous and consistent note taking
— The basic forms
— Special forms
— The Report of Findings

PDF#5 Closing notes Self-assessment of your record keeping

PDF#6 Appendix with sample file , forms , a package of pain assessment tools and the answers to the quiz questions.

Learning Objectives

You will learn:

— How to construct forms that ensure you cover all the bases — keeping patients safe and finding opportunities to build your practice
— How to formulate a clear, concise clinical impression and a realistic treatment plan
— How to prepare a written Report of Findings to educate new patients and others
— What Patient Based Outcomes Assessment Instruments are and how you can use them to assess the effectiveness of the care you provide
— To identify contraindications to care based on information from intake forms and the history of a complaint
— To define 'material risk' and understand the duty to inform patients of risks associated with care
— How to generate SOAP notes for ongoing treatments
— How to assess the adequacy of your clinical records

***

Use our easy online REGISTRATION to start your course.