According to recent estimates from the National Institute of Drug Abuse, more than 130 people in the U.S. die after overdosing on opioids. In 2017, opioid abuse was declared a public emergency by the Department of Health and Human Services (HSS). Medical transcription outsourcing companies help physicians to document opioid abuse in electronic health records (EHRs), which is necessary for continuity of care as well as for purposes of research and education. Proper clinical documentation can go a long way in ensuring quality treatment for opioid addiction and improving patient outcomes.
Characteristics of Reliable EHR Documentation
In response to HHS declaring the opioid epidemic a public health emergency in 2017, the American Health Information Management Association (AHIMA) put forward guidelines to help clinicians ensure reliable documentation of how patient use or abuse opioids. AHIMA lists the seven characteristics of optimal EHR charting as: clear, consistent, complete, reliable, precise, legible, and timely. According to the group, using these characteristics can help clinicians provide high-quality documentation, which is crucial for care and also for tracking the specifics of opioid use. AHIMA’s Opioid Addiction Documentation Tip Sheet demonstrates what clinical documentation for potential opioid abusers would look like if it was or was not based on these characteristics.
- Clear: Clear documentation means that when symptoms are recorded, a clear, supporting diagnosis should also be documented on the chart. The documentation should be as informative as possible and leave no room for uncertainty. For example, if a patient is admitted with lethargy and is addicted to heroin, not documenting the addiction would lead to lack of clarity in documentation.
- Consistent: Consistency means there should be nothing conflicting in the documentation. Small details matter. AHIMA provides the following example of inconsistency in documentation: “39-year-old male patient was admitted for opioid use. This is the second admission for opioid abuse in the last two weeks for her.” The questions that arise are: whether the patient was male or female and if the admission was for opioid use or opioid abuse.
- Complete: An example of an incomplete medical record would be when abnormal findings are documented without an associated condition. Investigations such as a positive drug screen should be documented as evidence of opioid abuse. A medical record would be also considered incomplete if all entries are not authenticated by the clinician’s signature and date.
- Reliable: To meet the reliability criterion, there should be a diagnosis in record that correlates with the opioid addiction therapy. The example in the AHIMA documentation tip sheet is that of a patient who is methadone dependent and is admitted for systolic CHF exacerbation. If the clinician documents that methadone therapy should be continued – without indicating the opioid dependence – the documentation would lack clarity and be considered unreliable. It is an instance of treatment provided without the documented condition.
- Precise: The data in a medical record should be precise with as many details as possible about the patient’s condition, treatment, and patient-provider interaction. Data integrity is extremely important as it is used to identify and track patients as they move from one level of care to another (AHIMA). Not documenting the specific drug that is being misused is an example of imprecise documentation.
- Legible: Illegibility in the medical record can lead to high error rates in documentation, improper treatment, poor continuity of patient care, dispensing of wrong medications, and coding audits. Documentation must be legible and easy to decipher.
- Timely: AHIMA gives the following example of poor quality documentation at the time of care being delivered:
- H&P Documentation: 55-year-old male admitted with right torus fracture of the distal right tibia after falling off of his front porch. Day 3 of admission: Right torus fracture of the distal tibia is healing. Will be admitted to rehab for drug dependency and mental health issues.
AHIMA points out that the above documentation is poor because it does not indicate:
- the patient’s drug dependency and mental health issues present on admission
- the drug that the patient is dependent on
- the mental health issue the patient has
When it comes to treating opioid dependency, optimal EHR documentation that tells the patient’s story completely and accurately can promote continuity of care and patient safety as well as improve research and education.
To deal with this challenging public health crisis, the HHS is focusing its efforts on five major priorities:
- improving access to treatment and recovery services
- promoting use of overdose-reversing drugs
- strengthening understanding of the epidemic through better public health surveillance
- providing support for cutting-edge research on pain and addiction
- advancing better practices for pain management
As physicians support HSS in its goals, they can rely on an experienced US based, HIPAA complaint medical transcription company to ensure the accuracy and quality of EHR documentation and avoid errors that can undermine patient care.