Dialogue Volume 13 Issue 3 2017 - Page 42

PRACTICE PARTNER But while clinicians across the province have begun to embrace digital health, many have yet to realize the full potential of EMRs maintaining a proper CPP is mandatory and highly recommended for other scopes of practice. But Dr. Habert says it’s not uncom- mon to see incomplete or even absent CPPs in EMRs. “A really good CPP is 70% of the battle. Everything follows from that. Doctors need to take the time needed to make sure their CPPs are thorough and well organized.” He also emphasizes the importance of good SOAP notes; a documentation style recommended in the College’s Medical Re- cords policy. Most EMRs use a SOAP (sub- jective, objective, assessment and plan) for- mat, and while younger doctors have been trained on SOAP, the method isn’t instinc- tive for many older doctors. Dr. Habert says it’s important to strike a balance between too much and too little detail in notes, and to consider use of guideline-based tools (such as the PHQ-9 depression questionnaire and Rourke Baby Record). And while templates and quick entry features in EMRs can be helpful, he cautions against relying on pre- populated templates since they don’t accu- rately reflect every doctor-patient interac- tion. Dr. Habert advises doctors to complete all notes and any referral forms in the exam room during the patient visit, rather than at the end of the work day. “There’s no way you can remember everything you’ve done over the course of a day in full detail.” Building 42 DIALOGUE ISSUE 3, 2017 sufficient time into each patient encounter to include time spent documenting is key. Organize preventive care Dr. Habert says that most EMRs don’t have a defined section for preventive care and health maintenance information. So, physi- cians should take time after adopting the technology to determine where this informa- tion should be kept on their EMR so it fits practice workflow and is easily accessible when it’s needed by College assessors. Effec- tive organization of routine immunization records should be carefully considered, and preventive care tests such as mammograms, pap smears, FOBT/colonoscopy, and bone mineral density should be properly docu- mented and kept current. Dr. Habert says this is where Peer Leaders like him can add value, since they can share organization tips that have worked for their practice, and help determine how to adapt that experience so it fits other practices’ needs. To find out more about how Ontari- oMD Peer Leaders like Dr. Habert can help advance your EMR use or to request an appointment, visit ontariomd.ca/products- and-services/peer-leader-program. There is no fee for this sevice, but partici- pating physicians must be using a certified EMR. MD