Documentation is essential to support the evaluation, the reason for prescribing an opioid, the nature and intensity of the pain, the overall pain management treatment plan, the presence of any recognized medical indications for the use of a controlled substance, any consultations received and a periodic review of the status of the patient. Chart everything. The medical record should include, at a minimum:
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- The complete medical history and a physical examination, including history of drug abuse or dependence;
- Diagnostic, therapeutic and laboratory results;
- Evaluations and consultations;
- Treatment objectives;
- Discussion of risks and benefits;
- Medications, including date, type, dosage and quantity prescribed;
- Instructions and agreements;
- Periodic reviews;
- Results of any drug testing;
- A photocopy of the patient’s government-issued photo identification; and
- If a written prescription for a controlled substance is given to the patient, a duplicate of the prescription.
Physicians who have these safeguards in place will be in a sounder position in the event they find themselves the target of the ongoing crackdown on physicians who are prescribing opiates outside the bounds of accepted medical practice. Also, be sure to check your state’s laws, as these agreements may be legally required. If you are using a controlled substance agreement template, now is the time to review it to ensure that all parties are best protected. If your practice has not yet started using a controlled substance agreement, now is the time to consult with a health care lawyer.
Steven M. Harris, Esq., is a nationally recognized health care attorney and a member of the law firm McDonald Hopkins, LLC. He may be reached at email@example.com.
Reprinted with permission from the American College of Rheumatology.