Proper Documentation a Critical Aspect in Chronic Pain Management

Pain ManagementAccording to the Institute of Medicine of The National Academies, up to 100 million Americans suffer from chronic pain. Good documentation is crucial when treating chronic pain patients. The physician has to ensure accurate pain management transcription of the dictated patient records in order to set the framework for the evaluation of the treatment plan and subsequent actions. The lack of complete and clear documentation in patient medical records can have a negative impact on clinical preparedness as well as the revenue of the healthcare practice since documentation is the key to proper billing.

Chronic Pain Treatment – Key Points that Need to Be Documented

An article published in Baylor University Medical Center Proceedings (BUMC Proceedings) discusses the main points that need to be documented when providing care for chronic pain patients. They are:

  • Patients’ prior treatment history: This should include history and physical, progress notes, orders, procedure reports, consultation reports, discharge summary, other physician reports, anesthesia reports, lab reports, imaging reports and so on. Comprehensive documentation will raise the threshold at which consultation and referral for other treatment options are needed.
  • All aspects of the manner in which their pain affects the patient: Complete documentation of the effects of chronic pain on the patient will provide the physician with many ways to validate the benefit of the treatment provided for the patient’s chronic pain.
  • Why a medical management plan is reasonable.
  • Subsequently, how the medical management plan is helping the patient.

According to the author of the article, putting in extra time and effort in documenting these matters will make subsequent documentation easier. It will provide the physician with a baseline from which it is easy to evaluate and document how the patient is responding to therapy, whether the treatment plan is proving beneficial for the patient, and whether further consultation or referral is needed.

In the electronic health record (EHRs), documentation mainly involves checking appropriate boxes. While inadequate documentation pertaining to patients with other medical condition such as hypertension, diabetes, chronic obstructive pulmonary disease may not lead to medical board discipline, regulatory scrutiny of chronic pain patients treated with opioids is very common. The physician needs to meticulously document follow-up office visits, urine drug screens, phone calls, emails, and even communications with the patient’s family as well as maintain an up-to-date medication chart.

With these rigorous documentation requirements, physicians are increasingly relying on reliable medical transcription companies for timely, error-free pain management transcription. Professional service providers ensure an integrated approach that blends EHR and medical transcription service where physician dictation is transcribed, edited, reviewed and fed into EHR fields.