OAP-104 · Bronze · Beginner
Clinical Recordkeeping, Consent and Records Management
A clinical record is only as useful as it is trustworthy.
Who it's for: Clinical staff
- Price
- $239 USD
- Length
- 7.2 hours
- Access
- 180 days
- Outcome
- Certificate of Achievement
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After this course you can
- Write a session note that is objective, timely, complete, and signed, and review another note against the same four tests.
- Get, record, and act on consent and its withdrawal so the record shows who agreed, to what, how, when, and until when.
- Store, correct, retain, and dispose of client records without losing the original entry or breaking the retention schedule.
- Apply Ontario rules on consent, capacity, substitute decision-makers, access, correction, and retention to client records, citing the official source for each rule.
How you pass
- Practice examScore 80% on the practice exam to unlock the final.
- Final examPass the final exam with 80% or higher.
- Recorded demonstrationRecord yourself doing the work. It is assessed with the assistance of AI, and a Verten assessor reviews on request.
- CertificateCertificate of Achievement, by assessed practical demonstration.
How recorded assessment works
Final exams include a recorded demonstration. You upload a recording of your screen and voice. AI services turn your speech into text and help rate it against the course rubric, and a Verten assessor reviews on request or by sample. We do not use facial recognition. Verten staff who run assessments can view it, and each view is logged. Recordings may be stored or processed outside Canada. We delete them 12 months after your result (6 months if you are under 18). You can withdraw consent at any time, and you can ask for an alternative assessment without giving a reason. Learners under 18 need a parent or guardian to consent.
Details: Assessment recordings in our Privacy Policy.
4 modules plus exams
Module 1: Session Notes That Meet the Standard
- Module overview8 min
- Knowledge test10 min
- Scenario practice11 min
- Workbook practice: observable rewrites and a note review35 min
- Recorded demonstration26 min
Module 2: Consent: Getting It, Recording It, and Withdrawal
- Module overview8 min
- Knowledge test10 min
- Scenario practice10 min
- Workbook practice: consent items and a withdrawal entry41 min
- Recorded demonstration26 min
Module 3: Records Storage, Corrections, Retention and Disposal
- Module overview9 min
- Knowledge test10 min
- Scenario practice11 min
- Workbook practice: retention dates and a correction39 min
- Recorded demonstration26 min
Module 4: M-L: Ontario Consent, Capacity and Retention Rules
- Module overview8 min
- Lesson 4: Access, correction, and retention5 min
- Knowledge test
Your certificate
Certificate of Achievementby assessed practical demonstrationYour nameClinical Recordkeeping, Consent and Records ManagementPractical demonstration assessed with the assistance of AI.Verten Academy
SampleEmployers verify it online
Every certificate has its own ID and a public page at academy.verten.ai/en/verify/ followed by that ID. An employer can open the link or scan the QR code on the certificate to confirm the course, your name and the date it was issued.
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About this course
A clinical record is only as useful as it is trustworthy. This course teaches you to write session notes that are objective, timely, complete, and signed; to get, record, and act on consent, including its withdrawal; and to store, correct, keep, and dispose of records the right way. A labeled Ontario module then covers the consent, capacity, substitute decision-maker, access, correction, and retention rules that apply to Ontario providers, each cited to its official source. The course teaches recordkeeping, not clinical methods. You practice on fictional records and pass by doing the work and explaining it out loud.
Important: This course is training, not legal advice. Verten Corp. is not affiliated with or endorsed by the Government of Ontario or the Ontario Autism Program.
Course details
- Level: Foundation
- Length: 7.2 hours across 4 modules, plus a Final Exam
- Format: Self-paced online, with fictional task packs. An instructor-led cohort is optional.
- Prerequisites: None. Basic computer skills, a microphone, and a word processor. Written for clinical staff; open to anyone who writes or signs client records.
- Course version: 1.0