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.
***
In-Person
Overview
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.
- Identify red flags
- Establish a baseline
- Understand the patient's problem
- Create opportunities for patient education,
practice building and research
Classroom Strategies
- Lecture and interactive discussion following
contents of notes package
- Laminated sample forms to view and discuss
- File folder with '6 forms' project – working
examples of how to customize
- Practical activities scattered throughout
- Whiteboard/flipchart summaries of points
generated by brainstorming
Course Outline
- Why keep records, Intake forms
- History form
- Physical examination form
- Clinical impression, treatment plan, informed
consent
- Ongoing treatment records, reassessments
- 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:
- Analyze intake forms as to their usefulness in
collecting the right kind of information
- Ask questions effectively using leading and
open-ended methods
- Decide which aspects of the physical
examination are most useful for the learner and their patients
- Follow best practices for documenting physical
findings
- Estimate ranges of motion and document them
accurately
- Develop a system for regularly updating
contact information
- Produce clear SOAP notes for ongoing treatment records
- Summarize a patient's case in a one page
report for the patient or another practitioner
- Appreciate the practice building opportunities
of customized office paperwork
- Formulate a clear, concise clinical impression
based on information gathered with intake/history/physical exam and
reports
- Prognosticate based on findings to set up an
expectation of results and the need for future care
- Create a realistic treatment plan based on
clinical impression and prognosis
- Identify contra-indications to care (absolute
and relative) and know when/how to decline services
- Know how to efficiently keep records that are
consistent, comprehensive and effective
- Appreciate the legal aspects of file
management
Activities
- Critique extant forms and samples of good and
bad record keeping
- Create a layout of required content for each
customized form
- Develop a unique header for forms which will
help build your image
- Analyze case history summaries to determine
what information is missing and what conclusions can be drawn
- Compile a file with all the forms which have
been generated during the workshop and use them to guide post-course
development of their own forms
- Interpreting abbreviations and pain diagrams
- Brainstorming to come up with 'top 3' lists
- Creating and interpreting ROM charts
- Working out a SOAP notes form that works for them
- Discussion of real life cases where record
keeping mattered
- Practice history taking at every visit
***
