Opioid Prescribing – Importance of Comprehensive EHR Documentation

opioid prescribing importance of comprehensive ehr documentation

Patients suffering from chronic pain rely on opioid therapy for pain management. However, opioid misuse, addiction, and overdoses are serious public health problems in the United States. Despite recent declines, medical use of opioids remains high and inconsistent across the U.S., according to the Centers for Disease Control and Management (CDC). While pain management medical transcription services can ensure timely and accurate medical records, not maintaining appropriate documentation can potentially expose clinicians to medico-legal scrutiny. When treating patients taking long-term opioids, providers need to ensure that prescriptions are medically justified and provide justification for continuing treatment with opioids.

A study published in Annals of Internal Medicine in 2018 reported that medical indication is not documented for many outpatient opioid prescriptions (www.healio.com). The researchers found that:

  • Opioids were prescribed for cancer-related pain in 5.1% of visits and non cancer pain in 66.4% of visits
  • Patients with no pain diagnosis were prescribed opioids in the remaining visits (28.5%)
  • Compared to new prescriptions, continued opioid prescriptions lacked a pain diagnosis (22.7% vs. 30.5%)

Documenting treatment of chronic pain patients with opioids

When prescribing opioids, the clinician needs to maintain comprehensive documentation for the initial visit as well as for follow-up visits. An article in Practical Pain Management Appropriate lists the current recommendations and requirements for documentation of visits with patients prescribed opioids and other controlled drugs for chronic pain as follows:

Initial visit: The following information should be documented in the patient’s chart:

  • Specific information about past treatments: In addition to the ongoing problem, the clinician should document the doses and duration of medications tried, and if a medication was stopped, the reason
  • The type and intensity of the pain
  • Results of previous diagnostic studies
  • Treatment plan and goals – goals should be as specific and measurable as possible. Documentation of the plan should include a list of all prescriptions given, including dose and quantity, as well as referrals for lab tests, imaging studies, and physical therapy or other specialists

The guidelines recommend requesting and reviewing the patient’s old records and obtaining a baseline urine drug screen (UDS) at the initial visit. The documentation should include the last dose of each medication taken including the date and time. The clinician should also check the patient’s history on the state’s Prescription Monitoring Program (PMP website and document this in the patient’s chart, including whether there are any results of concern.

Follow-up visits: How often the patient should be seen would be based on how stable the patient is, how often a physical exam is needed, and the clinician’s reckoning as to the patient’s ability to follow the recommended regimen.

The article recommends that documentation for the follow-up visit based on “5 A’s”:

  • Analgesia: The level of pain on a scale of 1 to 10
  • Activities of daily living: Specific information about what the patient actually does (e.g., “Walking the dog for 15 minutes, about half a mile.”)
  • Adverse effects
  • Aberrant drug-related behaviors
  • Affect-the patient’s mood

Appropriate documentation of evaluation and assessment in follow-up visits would include the following:

  • Review of previous office visit: At the start of the follow-up visit, the clinician should review the plans documented in the record for the preceding office visit with the patient and the outcomes of each plan. Things to evaluate include whether any lab tests and imaging studies were ordered, if the results are in the chart, if a UDS done, and if the results are “consistent” or good.
  • Assessment and plan: The clinician should summarize and document the patient’s current medical status, level of compliance, and also the clinician’s reasoning for continuing the same regimen, making changes in the patient’s medication management, making a new referral, altering the goals, and compliance concerns. If a prescription is renewed by phone, email, or fax between visits, this must be documented on the master medication list.
  • All electronic communication: All electronic communication with the patient, such as phone calls, faxes and emails, should be documented.

The article cautions clinicians about problems associated with utilizing the copy-and-paste function in EHRs when documenting treatment of chronic pain patients with opioids. Copying and pasting past entries into the current EHR can lead to serious errors, negatively impact care, and increase risks of malpractice.

Physicians can protect their practice with thorough documentation of opioid prescribing in the medical record and adhering to extra regulatory requirements. HIPAA compliant medical transcription can ensure safe and effective documentation of opioid management.