The Cheese Trail of Good Documentation!

Author: Jennifer Bolen

The landscape for prescribers is changing today. Many state licensing boards are adopting new rules or guidelines. Many of them are looking at the CDC guidelines and trying to figure out do they need to incorporate them. Prescribers really need to understand what their licensing boards are doing and how their rules are changing and then think of ways to put that into practice, especially in the area of documentation. Many times prescribers don’t really realize that they’re not communicating what’s in their head about the patient, and that’s valuable, to protect their practice and to provide quality care to the patient. With established patients, document why you’re prescribing the opioid, why this person should stay on opioid therapy, whether you’ve tried to taper, whether you’re using additional types of treatment that are non-drug in nature. Things like that really signal to the regulatory authorities that you know what you’re doing, and you’re updating the treatment plan frequently. With new or inherited patients, be sure you have a summary of where that patient has been. Be sure you’re communicating to your state licencing board to say ‘I’ve done a treatment plan. I’ve examined these things. I’ve done the informed consent, the treatment agreement and we’ve set goals with the patient. They’ve got skin in the game and we’re working together to address their chronic pain issue. Opioids are either part or not part of the plan and here’s why.’

Whether you’re in primary care or you’re a pain specialist, you should really plan for having some sort of peer-review or expert review at some point in time. Seek other people's advice. It’s like creating a witness for yourself. I think those relationships need to be better cultivated and I think they’re very valuable if it comes down to some sort of legal proceeding. You really want to have a peer as a witness and you want to have the specialist in the community as a witness if you are the primary care clinician. Pain specialists need to do the same thing because it is valuable to have another person’s review, perhaps to note ‘you didn’t really say what you thought you were saying in these records. Let’s go back and make it clearer.’

I think it’s safe for primary care to be engaged in prescribing. Don’t run out the back door when the pain patient comes to call. Don’t give up. There are so many good people who need your care. You will get through this challenge right now with opiophobia, so stick with it and learn your licensing board rules or guidelines and try to follow those. Make your own checklist, think about what you’re documenting, and be sure you leave a cheese trail for the rats that might look at your chart.

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