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36 minutes

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November 29, 2021

Learning Objectives for Module 3: Know the purpose of good medical documentation Know the overall structure of a medical chart …

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Learning Objectives for Module 3:

  • Know the purpose of good medical documentation
  • Know the overall structure of a medical chart
  • Understand the SOAP format 
  • Know what SOCRATEs relates to
  • Know how to use descriptors in medical documentation
  • Know how to utilise a template for documentation
  • Write medical notes as you watch the doctor interview patients.

Introduction

Documentation is the primary role of the doctor’s clinical assistant, and it should be thorough and consistent.

You are going to learn about how to write the notes on behalf of the doctor which is a record of the interaction and conversation between the patient and the medical professional.

    • Module 3: Introduction 00:00:00
    • Module 3: SOAP Format 00:00:00
    • Module 3: Subjective Information 00:00:00
    • Module 3: Transcript and Scribe Notes 00:00:00
    • Module 3 Activity 1: Questions and Answers 00:06:00
    • Module 3 Activity 2: Video HPI 00:06:00
    • Module 3 Activity 3: Transcription Practice 00:00:00
    • Module 3: Descriptors and Ways to Describe Symptoms 00:00:00
    • Module 3 Activity 4: Case Review and Analysis 00:00:00
    • Module 3: Other Subjective Information 00:00:00
    • Module 3: Objective Information 00:00:00
    • Module 3: Assessment 00:00:00
    • Module 3: Plan 00:00:00
    • Module 3 Activity 5: Case 1 00:06:00
    • Module 3 Activity 5: Case 2 00:06:00
    • Module 3 Activity 6: Medical Notes 00:06:00
    • Module 3 Activity 7: Video Case Practice 00:00:00
    • Module 3 Final Assessment 00:06:00
    • Module Completion 00:00:00
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