Medical Record Keeping: Tools and Resources

Patient Records

CMPA article: Documentation

https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Documentation/documentation-e.html

CPSA: Patient record content

https://cpsa.ca/physicians/standards-of-practice/patient-record-content/

CPSA: Patient record retention

https://cpsa.ca/physicians/standards-of-practice/patient-record-retention/

CPSA: Physicians as custodians of patient records

AP_Physicians-as-Custodians.pdf (cpsa.ca)

CPSA: Closing or leaving a medical practice

https://cpsa.ca/physicians/standards-of-practice/closing-or-leaving-a-medical-practice/

Referral & Consultation

CMPA: Consultation & Referral

https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Consultations_and_Referrals/consultations_and_referrals-e.html

CPSA: Referral Consultation

Standards of Practice

https://cpsa.ca/physicians/standards-of-practice/referral-consultation/

Advice to the Profession

https://cpsa.ca/wp-content/uploads/2020/06/AP_Referral-Consultation.pdf

Self study module: consult and referral request letters

Microsoft Word – self study module 2014.doc (wrha.mb.ca)

QuRE two-sided checklist

https://www.albertahealthservices.ca/assets/info/hp/arp/if-hp-arp-qure-digital-checklist.pdf

Emphasizing the importance of referral letters

Physicians’ notes: The consequences of substandard communication for yourself, your colleagues and your patients

QuRE templates in EMR
- Healthquest
- Telus MedAccess
- Telus PS Suite
- Telus wolf
- QHR Accuro

A tool to assess the quality of consultation and referral request letters

From: Jose Francois. (2011). Tool to assess the quality of consultation and referral request letters in family medicine. CFP 57: May 2011, pg 574-5.

Episodic Care

CPSA: Episodic care

https://cpsa.ca/physicians/standards-of-practice/episodic-care/

Test Follow-up

CMPA: Test Results follow-up

https://www.cmpa-acpm.ca/en/education-events/good-practices/physician-patient/test-results-follow-up

Charting in specific circumstances

TIPS on writing procedural notes

How to Write a Procedure Note – CanadiEM

Charting in the ER

You searched for charting in the er – CanadiEM

APA Update Guidelines on Psychiatric Evaluation in Adults

https://www.aafp.org/pubs/afp/issues/2016/0701/p62.html

Charting Psychiatric notes

From: Bastiaens, L. (2013) Better psychiatric documentation: from SOAP to PROMISE. Current Psychiatry, March. Pg 50-51.

Medical Interview

Prescribing

What makes a Model Prescriber?

Usmaan Omer, Martin Veysey, Paul Crampton & Gabrielle Finn (2021) What makes a model prescriber? A documentary analysis, Medical Teacher, 43:2, 198-207, DOI: 10.1080/0142159X.2020.1839031
To link to this article: https://doi.org/10.1080/0142159X.2020.1839031

CPSA: Prescribing

https://cpsa.ca/physicians/standards-of-practice/prescribing-administration/

https://cpsa.ca/physicians/standards-of-practice/prescribing-drugs-associated-with-substance-use-disorders-or-substance-related-harm/

Medical Record Keeping_Course Handout

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