Documentation of Behavioral Health Risk Factors in a Large Academic Primary Care Clinic

To determine the prevalence of alcohol, smoking, and physical activity status documentation at a family health team in Toronto, Ontario, and to explore the patient characteristics that predict documentation of these lifestyle risk factor statuses.

Manual retrospective review of electronic medical records (EMRs).

Large, urban, academic family health team in Toronto, Ontario.

Patients over the age of 18 that had attended a routine clinical appointment in March, 2018.

Prevalence and content of risk factor status in electronic medical records for alcohol, smoking, and physical activity.

The prevalence of alcohol, smoking, and physical activity documentation was 86.4%, 90.4%, and 66.1%, respectively. These lifestyle risk factor statuses were most often documented in the "risk factors" section of the EMR (83.7% for alcohol, 88.1% for smoking, and 47.9% for physical activity). Completion of a periodic health review within 1 year was most strongly associated with documentation (alcohol odds ratio [OR] 9.79, 95% Confidence Interval [CI] 2.12, 45.15; smoking OR 1.77 95% CI 0.51, 6.20; physical activity OR 3.52 95% CI 1.67, 7.40).

Documentation of lifestyle risk factor statuses is strongly associated with having a recent periodic health review. If "annual physicals" continue to decline, primary care providers should final additional opportunities to address these key determinants of health.