Documentation Excellence Part 1: The Foundations of Professional Charting
MTAM
Lisa Goss
Zoom Room
1 Core Credit
MTAM Members: $15.00 +GST
Monday, October 19, 2026 | 6:30 PM – 7:30 PM
Registration closes Oct. 15th
Session Overview
Good charting starts with understanding what a professional health record is, what belongs in it, how it must be managed, and why it matters.
This foundational session takes RMTs behind the mechanics of professional documentation. Rather than focusing on a particular clinical encounter, we'll look at the rules, responsibilities and systems that surround your client records from MTAM's current documentation expectations and Manitoba privacy requirements to electronic charting, secure storage and the emerging use of artificial intelligence.
We'll also explore what makes documentation clear and defensible, how structured approaches such as SOAP and CARE can support clinical reasoning, how errors should be corrected, and some of the common documentation gaps that can create problems for practitioners.
The goal is to understand the “what, why and how” of professional documentation before we put those principles into practice in the next session.
Topics We’ll Explore
- Why clinical documentation matters
- The clinical, professional, legal and risk-management purposes of the health record
- Current MTAM documentation expectations
- What belongs in a clinical record
- Timing of documentation and late entries
- Manitoba privacy requirements and your responsibilities for personal health information
- Paper versus electronic records
- Secure storage, access, transmission, retention and destruction
- What happens to records when a practice closes
- Structured documentation: SOAP and CARE
- Finding the right level of detail
- What makes a record clear and defensible
- Professional and objective language
- Correcting errors and maintaining an audit trail
- Risks associated with separate or informal notes
- Electronic charting systems
- AI scribes, voice-to-text and automated documentation
- Consent, privacy and accuracy when using AI
- Common documentation gaps and how to prevent them
Lisa Goss brings a unique combination of clinical, regulatory, privacy and operational experience to health-care documentation. A regulated health professional for 30 years, Lisa has developed and implemented clinical documentation systems, policies and standards and has experience reviewing health records for quality, completeness and compliance.
She has also served as the CEO of a health regulator and as a member of a professional College board, giving her experience with documentation from both the practitioner and regulatory perspectives. Her work includes privacy, health information management, quality improvement and the development of practical systems that support safe and accountable health-care practice.
Lisa's approach focuses on helping practitioners understand not simply what to write in a chart, but the broader professional responsibilities that surround the creation, use, protection and management of the clinical record.
A full refund will be given to anyone cancelling 5 or more days before the course start date. A 50% refund will apply to any cancellation between 3 and 5 days before a course. Cancellations made WITHIN 72 hours or no shows will not be refunded. Consideration will always be given to extenuating circumstances.