Medical Record Keeping


The medical record facilitates good care. With contemporaneous documentation of patient encounters, the reflection and review can reinforce the consistency, completeness and quality of your clinical activities. This course aims to address sufficient documentation, which is central to patient safety and continuity of quality care.

Upon completion of the course, participants will be equipped to:
  • Recognize the general principles and multiple purposes of medical record documentation
  • Identify the elements and characteristics of appropriate documentation of patient encounters
  • Use the SOAP-based tool to self-evaluate and improve the practice of documenting patient encounters
  • Practice effective written communication of referral or consult letters

Participants will complete a series of learning activities.

Once registering for the course, the pre-workshop activity is available for you to complete at any time.

The combination of a workshop followed by post-workshop activity and a three-month-post-workshop webinar will be offered several times per year.

Completion of the online activities is the prerequisite for attending the workshop and the webinar.

Step 1

Self-paced modules with online submission requirements

Step 1
Step 2
Group Learning

Three-hour in-person or virtual workshop

Step 2
Step 3

Practice the strategies learned; complete online submissions

Step 3
Step 4
Group Learning

Three-month-post-workshop, 60-minute webinar

Step 4
  • It is not recommended to access the online modules on smartphones at this point as your learning experience might be compromised.
  • There are required learning activities in the modules, such as reviewing text and video materials, submitting your own documents, responding to open-ended questions, responding to some short surveys.
  • ‘TAKE NOTES’: To make notes for your own use, click on ‘TAKE NOTES’ at the upper right corner of your screen to open the notes field. All the course notes you have made can be found in a full list in the page of ‘My Courses’.
  • ‘RESUME LEARNING”: Please be aware that it will take you several hours to complete the modules. For the convenience of self-paced learning, you may exit from the middle of the course and come back later. When you log into the e-learning portal again, click on ‘RESUME LEARNING’, and you will be redirected to where you left last time.

This three-credit-per-hour Group-Learning program meets the certification criteria of the College of Family Physicians of Canada and has been certified by the University of Calgary Office of Continuing Medical Education and Professional Development for up to 30 Mainpro+ credits.

This activity is an Accredited Self-Assessment Program (Section 3) as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada, and approved by the University of Calgary Office of Continuing Medical Education and Professional Development. You may claim a maximum of 10 hours (credits are automatically calculated).

You may also perform Linking Learning exercises around a question you ask yourself as a result of learning from this course at: Each completed Linking Learning exercise earns up to five Mainpro+ certified credits.

Accredited Royal College MOC Section 1 and Section 3 credits are eligible for certified Mainpro+ credits, up to a maximum of 50 credits per five-year cycle; any additional credits are eligible as non-certified Mainpro+ credits. MOC Section 3 accredited activities can be claimed at 3 credits per hour up to the cycle maximum.

  • This course has received no commercial sponsorship support.
  • This course is co-developed by the College of Physicians and Surgeons of Alberta and the University of Calgary CME&PD, and was planned to achieve scientific integrity, objectivity and balance.
  • Faculty disclosure
Heather ArmsonMD MCE CCFP FCFPNothing to discloseProfessor, Department of Family Medicine;Assistant Dean, Personalized Learning, CME&PD, University of Calgary
Michael CaffaroMD CCFPNothing to discloseAssistant Registrar and Complaints Director,
College of Physicians & Surgeons of Alberta
Nigel FlookMD CCFP FCFPNothing to discloseSenior Medical Advisor,
College of Physicians & Surgeons of Alberta
Monica SargiousMD CCFP FCFPNothing to discloseClinical Assistant Professor,
Section Chief Community Primary Care,
Department of Family Medicine-Calgary Zone

Heather Armson MD MCE CCFP FCFP (Chair)
Michael Caffaro MD CCFP
Sarah Weeks MD FRCPC
Nigel Flook MD CCFP FCFP
Monica Wickland-Weller MD
Utkarsh Subnis PhD, MBBS (CME Representative)

This program has received educational grants from the College of Physicians and Surgeons of Alberta.

Material presented are in compliance with the University of Calgary Copyright Policy, Acceptable Use of Material Protected by Copyright.

Course materials are for individual use only and not to be distributed.