Dr. Lisa Bonang, presenter of the medical record keeping session at the January Welcome Collaborative.

For physicians new to practise in Nova Scotia, navigating a new health-care system involves more than just clinical knowledge. That’s where the Welcome Collaborative’s session on medical record keeping comes in, helping to strengthen participants’ record keeping skills as they transition into practise.

Family physician Dr. Lisa Bonang brings both clinical and educational experience to her session. Her work with the Welcome Collaborative grew out of her role as a Director of Faculty Development in the office of Continuing Professional Development and Medical Education at Dalhousie University, where she was tasked with developing an online course on medical records. “Through that work, I’ve become someone who has a little bit of knowledge about medical records keeping,” she said, adding that this background led the College to invite her to present on the topic.

At its core, Dr. Bonang’s session focuses on the fundamentals. She begins with a review of the SOAP format—subjective, objective, assessment, and plan—before moving into practical guidance. “We get into the do’s and don’ts, tips, and looking at standards of care,” says Dr. Bonang.

“I always hope that every participant takes away some information that can be easily integrated into daily practise to support seamless communication, collaboration, and quality patient care.”

“The session focuses on how to make documentation the best we can make it to try to reduce risks, not only for the patients, but for other team members, as well as for the physicians themselves.”

For international medical graduates, documentation can present unique challenges. While clinical practise may be familiar, the systems and standards often are not. “The medicine is fairly the same, but how we document may be different. There may be subtle differences in the standards of care,” Dr. Bonang explains.

Just as important, the session emphasizes how medical records support collaborative, continuous care. “It’s about facilitating a good transfer of care or accountability, so nothing falls through the cracks,” says Dr. Bonang.

For Bonang, the goal is practical and empowering. “I always hope that every participant takes away some information that can be easily integrated into daily practise to support seamless communication, collaboration, and quality patient care.”

For more information on medical recording charting and management please read the College’s Professional Standards Regarding the Management of Medical Records and Professional Standards and Guidelines Regarding Charting.