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Documentation


Document, document, document!

How to document


Communication with other members of the team is optimized when:
  • a standard format (e.g. SOAP) is used
  • only standard abbreviations, or none at all, are used
  • notes are objective and relevant
  • writing is legible
Adhering to these principles is also important when your work is being assessed by an examiner for the College
Regulatory authority, professional:  Licensing body for a profession.
Provincial/territorial medical regulatory authority (College)
Body that regulates the practice of medicine in each province or territory to ensure the public receives quality medical care from physicians. The responsibilities include:
- Issuance of certificates of registration to allow the practice of medicine,
- Maintenance of standards of practice,
- Investigation of complaints against physicians, and
- Remedial education or discipline for those guilty of professional misconduct or incompetence.
The medical profession is self-regulating in Canada. Each authority has an investigative process and committee structure to make decisions on different issues and complaints.
, an expert, or a lawyer.

SOAP stands for:

  • Subjective (e.g. history)
  • Objective (e.g. physical examination)
  • Assessment of the patient's condition
  • Plan for further investigation or treatment

The CMPA does not endorse any particular charting method.