By Dr. John Crosby, OMD Physician Peer Leader and practicing family physician in Cambridge, Ontario
OntarioMD (OMD) offers a variety of blog posts to support clinicians with digital health tips and tools for varying skill levels. Content is tailored towards clinicians’ diverse needs, and articles may range from beginner to immediate and advanced users.
This blog post features useful tips on leveraging your computer to save time when managing the top 12 diagnoses in family practice, offered by Dr. John Crosby. He uses a PS TELUS EMR, but these tips and tools can be adapted to other EMRs. Contact OMD at email@example.com to ask how you can do this with your EMR.
Before I even begin a patient visit and come to a diagnosis, I set my cell phone to buzz in 10 minutes before I see the patient so I have their record open and I’m ready to go.
- High Blood Pressure. I have a stamp or template in the computer that has all the history and physical in a SOAP =
A (ssement) and
P (lan) format.
I look at the patient and don’t type. I ask the patient how they are doing then shut up and let them talk. I then ask if they have any ankle swelling, shortness of breath, chest pain, light-headedness or headaches. I then do their blood pressure, listen to their chest and heart, and check peripheral pulses and ankles for oedema.
I ask permission to type (‘do you mind if I type this up to make sure it is accurate?’), then pivot to the computer. I fill in my template.
If their BP is normal, I remind them why we do blood pressure (to prevent stroke and heart attacks) and that they can’t feel it when it is high. If it is normal, I see them in six months and give them a handout (in the computer) to reinforce my teachings. I print a lab slip on my secretary’s printer (exit strategy) and type on it ‘back in 6 months’ so I don’t have to interrupt her.
- Arthritis. With anyone with a painful joint, I use a template and get a history and examine the joint. I do an x-ray if I suspect osteoarthritis and wait until they return a week later to go over the x-ray with them, and then advise the patient re: medications, physiotherapy, weight loss, bracing, ice and heat and rubs. I have a handout I give the patient, and I refer to physiotherapy with the consult letter function on my computer. It includes my history, physical and the x-ray results.
I refer to an orthopod early if it looks surgical. We have central intake now so we get an instant appointment by email. No more fax limbo.
- URI, or Upper Respiratory Infection (pre- and hopefully post-COVID-19). I use a computer template that asks how long they have had it, if they have a cough, sputum, ear pain or a temperature. I then examine their ears, nose, and throat, palpate their neck for lymph node enlargement, take their temperature and listen to their chest. If it is viral, I explain that antibiotics are not only useless, but also harmful as they may cause allergies, diarrhea or superbugs.
I give them a handout from the computer on why they didn’t get an antibiotic.
If they need an antibiotic, I have a prescription function on my computer that writes it out. It blocks it if there are any allergies.
Also, there is an ‘off work’ letter writer on the computer.
- Abdominal Pain. I have a template that prompts me to ask what caused the pain, where the pain is—its quality and duration, what helps it and makes it worse, and what they have tried as a home remedy.
I then take their temperature, check ears nose and throat, listen to their lungs and palpate and auscultate their chest and abdomen. I do a rectal if needed.
I can order imaging by computer. If they need stat help, I can write a consult letter to the Emergency Physician.
- Depression. I have a stamp in my computer that prompts me to ask about the nine symptoms: are you tired, do you wake up in the middle of the night, are you crying, do you blame yourself and feel guilty, do you lack concentration, do you lack joy in things you used to love, has your weight gone up or down unintentionally, are you faster or slower than others, and are you suicidal?
If suicidal, I get immediate help for them. Otherwise, I give them my handout on depression and ask them to read it and set them up for counselling. I have them back in a week to go over the handout.
- Prenatal. I use the Ontario prenatal forms and get (delegate) my secretary (or if you have a nurse) to fill out as much as she can, then go over it with the patient for accuracy. I do the physical the next visit. I tell the patient to read the book, ‘What to Expect When You Are Expecting.’ I leave the pelvic exam for the obstetrician or midwife to avoid double discomfort.
- Well Baby Care. I use the Rourke Baby Record in my computer for every visit. It helps you remember all the milestones, safety and feeding tips.
I always talk to the parents before examining the baby to avoid having to shout over the crying. I always compliment the parents and tell them to never hesitate to call for advice, which we have, 24/7/365 through our Ontario Telehealth service and my office.
- Diabetes. I use a stamp and check feet and eyes. The patient has their shoes and socks off before I see them and they bring their list of sugars since the last appointment. We go over their labs and how they are doing, then I examine their heart, lungs, peripheral pulses, skin and blood pressure. I weigh them as I am talking to them.
If stable, I bring them back every three months.
My secretary gives them a lab slip signed by me to do blood sugars, HbA1C, creatinine, urine for protein, lytes, CK, liver profile, and lipids one week before each visit. I send them to Diabetic Day Care with their spouse to learn about diet and exercise and how to handle their disease. (Delegate to the patient and Diabetic Day Care.)
- Urinary Tract Infection. I use a stamp that asks how long they have had symptoms, do they have frequency and burning, do they have any temperature or flank pain. I examine their abdomen and take their temperature and if it is a simple UTI, I do a urinalysis, routine and micro and culture and sensitivity and if the results can’t be back in a reasonable time, I start an antibiotic.
- Chronic Obstructive Pulmonary Disease (COPD). I ask about sputum change and shortness of breath. I inquire re: smoking and encourage them to stop and try medications to help with this. I examine their ears, nose and throat and chest. I refer them to the COPD clinic and give them an antibiotic to take if they get a URI. I encourage them to get flu, pneumonia and three COVID shots. I don’t order a lot of respiratory tests as the respirologist will just repeat them anyway. Same for cardiology.
- Physicals. I do one every three years on healthy, symptomless patients because I am in a capitated payment system. If you are fee for service, do them yearly with the first appointment when you are fresh and not overbooked.
I give them my Ocean Wave Tablet by CognisantMD.com, which does the functional enquiry wirelessly. I can see other patients while they are filling it out. It is more thorough than I am and the patients will answer more truthfully.
I weigh the patient and do their height and blood pressure. With women, I bring my secretary in to chaperone breast and pelvic exams.
I do labs for a complete blood count, lytes, blood sugar, cholesterol and FIT (fecal immunochemical test) for colon cancer.
- Hypercholesterolemia. I have a stamp for this too and go over their labs and meds. I do their BP and examine their heart, lungs and peripheral pulses. I ask about muscle aches and, if stable, see them in 12 months and do a lipid profile, creatinine, BS, lytes, CK and liver profile.
The last patient in the morning is booked at 11:30 am so we can put our phones on voice mail and enjoy an hour off for lunch.
The last patient of the day is booked at 4:30 pm so I can be home by 5 pm.
If I have an evening clinic, I take the afternoon off to rest to avoid 12 hours of straight work.
Visit Dr. Crosby’s website for more tips and resources, including his eBooks on burnout and time management.
For other tips, questions about EMRs and support with digital health and virtual care tools for your practice, contact firstname.lastname@example.org and connect with OMD’s expert staff and clinician Peer Leaders. OMD can help you with whatever you need! Join the discussion and share your thoughts in the comments field below.