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
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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