Board rule 170.3 basically provides a step-by-step guideline on how to document the treatment of pain. The key to documenting the treatment of pain is to describe one’s legitimate medical purpose for the treatment of pain, based “upon accepted scientific knowledge of the treatment of pain.” The Board basically wants one to follow five (5) steps documentation steps:
1. A documented medical history and physical examination, including an assessment and consideration of the pain, physical and psychological function, any history and potential for substance abuse, coexisting diseases and conditions, and the presence of a recognized medical indication for the use of a dangerous drug or controlled substance.
In my experience included in this history and examination, the physician should review and have copies of all prior treatment records. You need to have a documented pain scale. In some cases, a psychological evaluation is warranted and should be a common treatment tool. A written inquiry to local pharmacies and documenting this investigation is good protection if you are not sure. The physician should exhaust non-controlled substance options first: steroids, PT, OMT, and the like. If the patient has immediately rejects this notion, you need to ask why? What have the other physicians said and why? What were the past treatment options for the patient, and were they followed? If so, what were the results? If not, why not?
2. A written treatment plan individually tailored to the patient that can objectively measure results, including but not limited to pain relief and/or improved physical and psychosocial function. This treatment plan must consider pertinent medical history and physical examination as well as the need for further testing, consultations, referrals, or use of other treatment modalities. This treatment plan should have both objective and subjective treatment goals.
Part of this individualized treatment plan should be a pain contract. Within this contact, the patient must agree that you will be the only physician to prescribe pain medications except in emergency situations, defined to mean only hospitalizations. That the patient agrees to fill prescriptions at only one specific pharmacy of their choosing, agreed upon by the physician. That lost medications or medications taken before the refill period will not be replaced but for emergency situations. That if the physician makes a referral to other physician or for a diagnostic study, the patient must do so. Failure to follow these guidelines will result in the physician firing the patient with 30 days notice a referral to three or more physicians, or refer them to insurance provider
A normal check up schedule should be followed, with appropriate physical examinations and diagnostic studies. All consultant reports, labs and studies must be included within the patient record. Occasional inquiries to the designated pharmacy and to others in town should be done to ensure compliance with the contract.
3. The physician should discuss the risks and benefits of the use of controlled substances with the patient or guardian.
This must be well documented in the medical record. A statement of “patient educated” is not enough. If the patient or family members have questions, answer the questions, and attempt to document the general tone and response to the questions. It is even better to follow-up on such a Q &A session with a letter to the patient and/or family regarding these issues. The letter must be included in the medical record. At this counseling session, basic written information should also be provided. Even if should action is basic protocol for your office, I would recommend this be also included in the medical record.
4. The progress of the patient should be noted at reasonable (regular) intervals to evaluate the treatment objectives. As the subjective and objective progress or regress of the patient should be evaluated and the individualized treatment pain can and could be modified, including any new information about the etiology of the pain.
As noted before, the patient should be seen a regular intervals. I would recommend on a thirty day cycle. This will allow you to control the prescriptions and not have to rely on refills. It controls access to the medications all the while allowing you to see the month to month status of the patient.
5. Complete and accurate records of the care provided must be kept. When controlled substances are prescribed, names, quantities prescribed, dosages, and number of authorized refills of the drugs should be recorded, keeping in mind that pain patients with a history of substance abuse or who live in an environment posing a risk for medication misuse or diversion require special consideration.
This can become a record keeping nightmare. A good method to comply with this provision is to photocopy the prescriptions and place it in the medical record itself. For patients at higher risk for substance or possible diversion, document whatever safe guards utilized to continue to have the controlled substances are used for the legitimate medical purpose. This includes counseling, charting by the patient, drug screens, and the like. Again, the key is to document.
This is merely a brief outline. It is critical to review Board rule 170. If you plan to work in the area of chronic pain, review the rules often, consult with an expert on your documentation, and take annual CME in this area.