medportal CDB | Taxonomy | McMaster Program Competencies / 4.5 Maintain comprehensive, timely, and legible medical records

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McMaster Program Competencies

4.5 Maintain comprehensive, timely, and legible medical records

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Activities

Ethics - Consent
PC Session

Part 1 / Professional Competencies 1 / Week 2

Ethics - Confidentiality
PC Session

Part 1 / Professional Competencies 1 / Week 4

Patient Safety
PC Session

Part 2 / Professional Competencies 2 / Week 3

Developmental Disabilities
e-Learning Module

Part 4 / Medical Foundation 4 / Brain and Behaviour

MSE part 1: Assessment of mood and anxiety
e-Learning Module

Part 4 / Medical Foundation 4 / Brain and Behaviour / Week 1

Intro to the Mental Status Exam
e-Learning Module

Part 4 / Medical Foundation 4 / Brain and Behaviour / Week 1

Suicide Risk Assessment
Clinical Skills Sessions

Part 4 / Medical Foundation 4 / Brain and Behaviour / Week 2

MSE part 3: Assessment of suicide and violence risk
e-Learning Module

Part 4 / Medical Foundation 4 / Brain and Behaviour / Week 2

Assessment of Psychosis & Delirium
Clinical Skills Sessions

Part 4 / Medical Foundation 4 / Brain and Behaviour / Week 3

MSE part 2: Assessment of psychosis
e-Learning Module

Part 4 / Medical Foundation 4 / Brain and Behaviour / Week 3

Form 1 of the Mental Health Act
e-Learning Module

Part 4 / Medical Foundation 4 / Brain and Behaviour / Week 3

Teaching OSCE (Psychology)
Clinical Skills Sessions

Part 4 / Medical Foundation 4 / Brain and Behaviour / Week 4

Medical/Legal Issues
PC Session

Part 4 / Professional Competencies 4 / Week 12

Anesthesia Clerkship
Clinical Exposure

Clerkship / Anesthesia Rotation

Examination: Trauma and burn
Clinical Exposure

Clerkship / Emergency Medicine Rotation

Emergency Medicine Clerkship
Clinical Exposure

Clerkship / Emergency Medicine Rotation

Emergency Medicine Triage Shift
Clinical Exposure

Clerkship / Emergency Medicine Rotation

Family Medicine Clinical Placement
Preceptor

Clerkship / Family Medicine Rotation

Internal Medicine Clinical Exposure
Clinical Exposure

Clerkship / Internal Medicine Rotation

Obstetrics and Gynecology Rotation (Hospital)
Clinical Exposure

Clerkship / Obstetrics and Gynecology Rotation

Obstetrics and Gynecology Rotation (Ambulatory)
Clinical Exposure

Clerkship / Obstetrics and Gynecology Rotation

Pediatrics Clerkship
Clinical Exposure

Clerkship / Pediatrics Rotation

Participate in the completion of Mental Health Act forms.
Essential Clinical Experience

Psychiatry Rotation

Psychiatry Clerkship
Clinical Exposure

Clerkship / Psychiatry Rotation

Psychiatric Emergency Service
Clinical Exposure

Clerkship / Psychiatry Rotation

Surgery Clerkship
Clinical Exposure

Clerkship / Surgery Rotation

Orthopedic Surgery Clerkship
Clinical Exposure

Clerkship / Orthopedic Surgery Rotation

Medical Subspecialty Selectives
Clinical Exposure

Clerkship / Medical Subspecialty Selective

Assessments

Anesthesia Clerkship Daily Evaluation
Preceptor Evaluation

Clerkship / Anesthesia Rotation

Emergency Medicine Daily Evaluation
Preceptor Evaluation

Clerkship / Emergency Medicine Rotation

Psychiatry Clerkship Clinical Placement
Preceptor Evaluation

Clerkship / Psychiatry Rotation

Psychiatric Emergency Service
Preceptor Evaluation

Clerkship / Psychiatry Rotation

Present oral and written reports that document a clinical encounter
Direct Observation Tool

Clerkship / Anesthesia Rotation / Psychiatry Rotation

Medical Subspecialty Selectives
Final Rotation Assessment

Clerkship / Medical Subspecialty Selective

Objectives

Apply standards of care, institutional policies, and standard operating procedures.
General Objectives

Professional Competencies 1

Identify the risk factors for suicide.
Activity Objectives

Part 4 / Medical Foundation 4 / Brain and Behaviour

Describe how to assess for suicide risk.
Activity Objectives

Part 4 / Medical Foundation 4 / Brain and Behaviour

Describe systematic mechanisms to increase safety in the delivery of inhalation and intravenous drugs including labeling of syringes, needle recapping, use of needleless systems, preventing hypoxic anesthetic mixtures, etc.
Clerkship Objectives

Clerkship / Anesthesia Rotation

Demonstrate thorough, clear, and concise documentation and charting.
Clerkship Objectives

Clerkship / Emergency Medicine Rotation

Write prescriptions accurately (under supervision).
Clerkship Objectives

Clerkship / Internal Medicine Rotation

Document the patient interview in a concise, organized written and verbal report.
Clerkship Objectives

Clerkship / Internal Medicine Rotation

Communicate results of the functional assessment in well-organized written & oral reports.
Clerkship Objectives

Clerkship / Internal Medicine Rotation

Document the findings of the physical exam in a concise, organized written or oral report.
Clerkship Objectives

Internal Medicine Rotation

Record the results of laboratory tests in an organized manner.
Clerkship Objectives

Clerkship / Internal Medicine Rotation

Dictate clear, succinct, and timely discharge plans.
Clerkship Objectives

Clerkship / Internal Medicine Rotation

To describe and perform normal prenatal care for an uncomplicated pregnancy.
Clerkship Objectives

Clerkship / Obstetrics and Gynecology Rotation

To identify and demonstrate the management of abnormal labour.
Clerkship Objectives

Clerkship / Obstetrics and Gynecology Rotation

To perform a complete obstetrical physical examination.
Clerkship Objectives

Clerkship / Obstetrics and Gynecology Rotation

To perform a complete gynecologic examination.
Clerkship Objectives

Clerkship / Obstetrics and Gynecology Rotation

To communicate the results of history in a well-organized oral and written report.
Clerkship Objectives

Clerkship / Obstetrics and Gynecology Rotation

To perform a physical examination on a labouring patient.
Clerkship Objectives

Clerkship / Obstetrics and Gynecology Rotation

To demonstrate proficiency in intrapartum cervical assessment to assess labour progress.
Clerkship Objectives

Clerkship / Obstetrics and Gynecology Rotation

To perform a physical examination on a gynaecological patient presenting for emergency care.
Clerkship Objectives

Clerkship / Obstetrics and Gynecology Rotation

Demonstrate clear, legible, and accurate ‘doctors orders’ (such as investigations, medication orders and outpatient prescriptions).
Clerkship Objectives

Clerkship / Pediatrics Rotation

Ability to record, present, research, critique and manage clinical information
Clerkship Objectives

Clerkship / Medical Subspecialty Selective

Learn the importance of medical documentation and how to document clearly and in an organized manner in the patient’s chart.
Clerkship Objectives

Clerkship / Medical Subspecialty Selective

Maintain comprehensive, organized, timely, and legible medical records.
Clerkship Objectives

Clerkship / Medical Subspecialty Selective

Demonstrate effective communication skills in conducting a patient centered interview, including exploring the patient’s illness experience as well as the family and social context.
Clerkship Objectives

Family Medicine TTR / Clerkship / Family Medicine Rotation

Demonstrate effective oral and written communication skills in documenting clinical encounters, making oral case presentations, prescription writing and making referrals to other care providers through clear, concise, efficient communication strategies.
Clerkship Objectives

Family Medicine TTR / Clerkship / Family Medicine Rotation

Undertake discharge planning including arranging and communicating follow-up plans.
Clerkship Objectives

Internal Medicine TTR / Internal Medicine Rotation

Accurately and succinctly communicate case presentations through written and verbal formats in various contexts (inpatient, outpatient, new patient, follow-up).
Clerkship Objectives

Internal Medicine TTR / Clerkship / Internal Medicine Rotation

Demonstrate organised, complete, informative, legible, and accurate written/electronic information related to clinical encounters (such as: admission histories, progress notes, and discharge summaries).
Clerkship Objectives

Pediatrics TTR / Clerkship / Pediatrics Rotation

Demonstrate proficiency in documentation and communication in psychiatry.
Clerkship Objectives

Psychiatry TTR / Clerkship / Psychiatry Rotation

Communicate results of the history in well organized written and oral reports
Clerkship Objectives

Surgery TTR / Clerkship / Surgery Rotation / Transition to Residency

Rectal examination
Clerkship Objectives

Surgery TTR / Clerkship / Surgery Rotation / Transition to Residency

Share results of the physical examination.
Clerkship Objectives

Surgery TTR / Clerkship / Surgery Rotation / Transition to Residency

Demonstrate management of practice environments, including charting, public reporting expectations, and malpractice risks.
General Objectives

Demonstrate appropriate behaviours, habits, and skills required for referral and consultation.
General Objectives

Tag Info

Taxonomy

McMaster Program Competencies

Tag Parent

4. Interpersonal and Communication Skills: Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

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