The program includes two required sessions and three selectives. Participants must attend the initial and final sessions and choose two of the three selectives. Each of these synchronous on-line web-based workshops will have pre-session readings, in-session required activities, and post-session application to practice assignments. Pre-workshop and post-workshop assignments are required. Post-workshop assignments are submitted electronically through an online platform.
Introduction: Opportunities and Challenges
Foundational material relevant to physicians of all specialties, including clinical notes and special considerations for electronic records
Selectives (Choose 2 of 3)
Selective 1
Hospital Medicine
Documentation requirements specific to providing care in a hospital or consultative practice including:
- Operative and procedure notes
- Consultation requests
- Consultation reports, follow up reports
- Discharge summaries
- Documenting Consent
Selective 2
Medical Records in the Circle of Care
- Documenting Consent
- Specific documentation requirements for Walk-in clinics
- Documentation requirements when a physician is not available or is closing a practice
Selective 3
Patient Centred Records
Documentation requirements for specific patient encounters including:
- General assessment/periodic health review
- Educational encounters with patients
- Medical records for chronic conditions
- Making good consultation requests
Conclusion: Good Medical Records Management
Foundational material relevant to physicians of all specialties including documenting when prescribing drugs, managing tests, and making corrections to records
The source material for this course is primarily from the many policies of the College of Physicians and Surgeons of Ontario (CPSO), the Ontario Health Insurance Policy (OHIP) Schedule of Benefits, CMPA documents, and the Information and Privacy Commissioner of Ontario.