Accreditation tip of the month – Indicator C7.1 G Our patient health records contain, for each active patient, lifestyle risk factors.
You must: document information relating to lifestyle risk factors such as height, weight and blood pressure in the patient health record.
Why record lifestyle risk factors?
Lifestyle risk factors such as smoking, nutrition, alcohol and physical activity are associated with many diseases. These risk factors are common among patients attending general practice. Of adult patients attending general practice encounters in 2013–14
- 62.7% were overweight (34.9%) or obese (27.8%)
- 13.5% were daily smokers
- 23% drank ‘at risk’ levels of alcohol
- Around 50% had at least one of the above three risk factors
- Only 43% of adults did at least 30 minutes of moderate intensity physical activity on most days.
Recording these risk factors in your medical software provides a more complete picture of your patient. It also ensures that they can easily be accessed, compared with previous results, discussed with individuals as well as searched and audited when providing population care for your patients.
Where do I record this in my medical software?
Below are guides for Medical Director, Best Practice, Zedmed and Genie for recording smoking, weight/BMI, alcohol and physical activity. Unfortunately, some of the products do not allow recording of physical activity in an auditable field which means that this information cannot be pulled out in a report. For these cases consider a practice policy on where to record physical activity that is consistent e.g. in the warnings box or in the social history box.
Medical Director:
Smoking: Patient details tab (keyboard shortcut ctrl + D) – smoking tab
Weight: Tools – Tool box – weight (key board short cut – ctrl+alt+w)
Alcohol: Patient details tab (keyboard shortcut ctrl + D) – alcohol tab
Physical Activity: Assessments – Physical Activity
Best Practice:
Smoking: Click tobacco icon then smoking
Weight: Click stethoscope icon or ALT+F3
Alcohol: Click alcohol icon
Physical Activity: Clinical
Zedmed:
Smoking: Patient maintenance tab – smoking
Weight: Stethoscope tab – Weight/Height/BMI
Alcohol: Patient maintenance tab – alcohol
Physical Activity: No formal place to record
Genie
Smoking: Patient Summary – Smoking Status tab
Weight: Tools tab. – Add a measurement – (calculates BMI)
Alcohol: Tools tab. – Alcohol Audit (there is also tick box in Patient Summary)
Physical Activity: No formal place to record
How can I improve this in my practice?
Consider having a practice policy on managing patient health information including:
- The routine collection of lifestyle risk factors at registration.
- Who inputs this data into the medical record?
- How often they are updated and by whom?
- Regular audits of record quality and feedback to clinicians to improve recording behaviours
Where can I get more information?
You can use the Cleansing Cat as part of CAT4 to identify patients who have not had their weight, alcohol status and smoking status recorded. More information can be found here: http://help.pencs.com.au/display/CG/Data+Cleansing+Report+Details
The RACGP also has several resources that you might find useful:
- Quality health records in Australian primary healthcare: A guide
- Improving Health Record Quality in General Practice
- The RACGP SNAP guide also provides useful information on why lifestyle risk factors are important
By Dr Jeannie Knapp.
Disclaimer: This article was provided by Dr Jeannie Knapp. While every effort has been made to ensure the information is accurate, North Western Melbourne Primary Health Network does not warrant or represent the accuracy, currency and completeness of any information or material included within.
