FOD 9: Documenting clinical encounters

Key Features

  • This EPA focuses on the application of written communication skills in a variety of formats such as assessment/progress notes; consult letters; discharge summaries; consult requests.
  • This includes a synthesis of the pertinent clinical findings, investigations, management plan, and clinical reasoning, as well as clear documentation of the plan for further care.
  • Any documents submitted for review must be the sole work of the resident.

Assessment Plan

Review of documentation by supervisor, clinical associate, subspecialty resident or senior resident

Use Form 1. Form collects information on:

  • Setting: inpatient; outpatient; emergency department; community; on call/after hours; simulation
  • Age: neonate; infant; preschool; school age; adolescent
  • Complexity: low; moderate; high
  • Format: admission note; consult letter; discharge summary; progress note; other (please specify)

Collect 4 observations of achievement.

  • At least 1 admission note
  • At least 1 discharge summary
  • At least 1 progress note
  • At least 1 consult letter

CanMEDS milestones

  1. ME 2.2 Synthesize and interpret information from the clinical assessment
  2. COM 5.1 Organize information in appropriate sections
  3. COM 5.1 Document all relevant findings and investigations
  4. COM 5.1 Convey clinical reasoning and the rationale for decisions
  5. COM 5.1 Provide a clear plan for ongoing management
  6. COM 5.1 Complete clinical documentation in a timely manner
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