Need for Accurate Documentation While Prescribing Drugs for Insomnia

InsomniaProper diagnosis of insomnia is important to prescribe appropriate drugs. Insomnia or sleeplessness may be due to a mental disorder, or a medical condition; it may be psycho-physiologic insomnia, idiopathic insomnia and so on. Unless the nature of the actual condition is known properly, it is not possible to determine which medications will work on the patients. Documentation of the patients’ health condition plays an important role in the proper diagnosis and treatment of insomnia.

The following details are very critical for doctors to diagnose insomnia:

  • Medical History – With this, doctors can understand whether the patients have any new or ongoing health issues, painful injuries, show symptoms or have a history of depression, anxiety, or psychosis, are going through highly stressful life events, use caffeine, tobacco, and alcohol or have long-distance travel history. They can also find out whether the patients’ family members have sleeping disorders with medical history. This information will help the physician to determine what’s really causing insomnia.
  • Sleeping History – Doctors will get details regarding the sleeping habits of patients with sleeping history such as how often they have trouble in sleeping, the time at which they sleep and get up on workdays and off, how long it takes them to fall asleep, whether they snore, how refreshed they feel after sleep and so on. Sleep history also include the details of what they drink or eat before sleeping, at what noise level they sleep, whether any distractions are there, whether they worry about falling asleep, staying asleep, or getting enough sleep, and what routine they follow before going to bed. With all these details, physicians can understand what’s worsening the patient’s sleeping disorder.
  • Results of Physical Exam and Sleep Study – Physicians often recommend physical exam or sleep study to rule out other medical conditions that cause insomnia and confirm that the ongoing condition is a sleeping disorder. So, the results of these tests in very critical for diagnosing insomnia.

Documenting all these details is critical for complete and accurate diagnosis. If all these details are not documented well, the consulting physicians will not get enough information to diagnose insomnia or they will get the wrong information about the patient’s condition. This will result in wrong diagnosis, which is very dangerous to the patients. There are several side-effects associated with sleeping pills. For example, benzodiazepines are widely used in the treatment of insomnia. However, its long-term use is linked to increased risk of abuse, misuse, and adverse events. Though dual orexin receptor antagonists (a drug type) are found to have limited side-effects and FDA approved Belsomra, an orexin receptor antagonist for the first time to treat insomnia, doctors can’t determine the dose of medication administered to avoid the severity of side-effects unless the medical history, sleep history and test results shows the adversity of sleeping order.

Documentation is important for doctors to receive correct reimbursement for prescribing insomnia drugs. With proper records, they can assign accurate reimbursement codes. Physicians have to submit prior authorization requests to receive reimbursement for certain drugs depending upon the age of the patient. Accurate documentation is vital to handle claim denials and the appeal process.

Electronic Health Records (EHRs) offer fast access to patient histories with pre-established sleep medicine encounter templates and point and click documentation of the visit. With a combined approach involving EHR and medical transcription, you can enhance the documentation quality further. It is because the possibility for making errors is quite high while copy pasting content more frequently to save time. Limited narrative documentation with templates is another disadvantage. Transcribing the physician’s dictations during a visit and populating those details into relevant fields within the EHR system through Discrete Reportable Transcription (DRT) technology ensures complete and accurate data within efficient electronic documentation system.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.