medportal CDB | Taxonomy | MeSH / Medical Records [L01.280.900.968]

Taxonomies

MeSH

Medical Records [L01.280.900.968]

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Activities

Teresa J. MF1 Respirology
Tutorial

Part 1 / Medical Foundation 1 / Respirology / Week 3

Integration Foundation Self-Guided Module: Impact of Technology and Financial Literacy
e-Learning Module

Part 5

Transition to Clerkship Self-Directed Learning Path
e-Learning Module

Transition to Clerkship / Clerkship

Orientation to Emergency Medicine
Large Group Session

Clerkship / Emergency Medicine Rotation

How Emerg Docs Think
Watching a Video

Clerkship / Emergency Medicine Rotation

How to present in the Emergency Department
Watching a Video

Clerkship / Emergency Medicine Rotation

Assessments

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

Clerkship / Anesthesia Rotation / Psychiatry Rotation

Objectives

Increase awareness of the impact of the electronic medical record system on the patient-physician relationship.
Activity Objectives

Part 5 / Integration Foundation

Identify positive and challenging aspects of technology, including the EMR in the patient care setting.
Activity Objectives

Part 5 / Integration Foundation

Students will learn the essential elements of sound record-keeping.
Activity Objectives

Part 5 / Professional Competencies IF

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

Clerkship / Emergency Medicine Rotation

Validate and obtain historical information from other relevant informants (eg. partner, caregiver, Community Care Access Centre, family physician) where indicated.
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

Communicate the relevant results of the examination in well organized written and oral reports
Framework Objectives

Medical Foundation 1 / Medical Foundation 2 / Medical Foundation 3 / Integration Foundation / Medical Foundation 4 / 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

Communicate results of the pediatric history in a well organized written and oral report
Clerkship Objectives

Pediatrics Rotation

Communicate results of the pediatric physical examination in a well organized written and oral report
Clerkship Objectives

Pediatrics 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 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

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

Communicate the relevant results of the examination in well organized written & oral reports
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

The learner will use appropriate record keeping when caring for patients. For example:
Framework Objectives

The learner will construct structured notes (e.g., subjective, objective, assessment, plan [SOAP] structure).
Framework Objectives

The learner will construct well-organised and comprehensive problem lists.
Framework Objectives

The learner will construct well-organised summaries/consultations to another health care provider.
Framework Objectives

Tag Info

Taxonomy

Tag Parent

Records as Topic [L01.280.900]

Use Count

36

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