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Opioid Prescribing Part 2: Appropriate Documentation of Follow-up Visits

Documentation of the initial evaluation of a chronic pain patient is only the beginning. Follow-up office visits, urine drug screens, phone calls, emails, and communications with family need to be meticulously documented and an up-to-date medication chart must be kept.
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Pain is one of the most common reasons patients visit a health care professional. Professionals spend a great deal of time learning how to diagnose and treat pain-related medical problems but much less time learning how to document the process. Traditionally, documentation by physicians has been minimal—just enough information scribbled in the chart so that the diagnosis, medications prescribed, procedures done, and referrals are recorded.

With the advent of electronic health records (EHRs), documentation is more detailed but often consists primarily of checking appropriate boxes. Although inadequate documentation rarely is a cause for regulatory scrutiny in patients with hypertension, diabetes, chronic obstructive pulmonary disease, etc., it is a very common reason for medical board discipline when it comes to treatment of chronic pain patients with opioids. Even if a physician is caring, knows his or her patient well, asks the right questions, is satisfied with the patient’s answers, and concludes that the patient is benefiting from the medications and is not abusing them—if this information is not documented in the chart, from a medicolegal perspective, it didn’t.

In Part 1 of this series, I described current recommendations and requirements for documentation of visits with patients who are prescribed opioids and other controlled drugs for chronic pain, with an emphasis on the initial visit.1 In Part 2, I will address appropriate documentation of evaluation and assessment in follow-up visits.

Documentation Actions

Documentation reflects the prescriber’s actions, so first let’s address how frequently patients should be seen for their pain problem, how often they need a physical exam, how often a urine drug screen (UDS) should be obtained, and whether a patient may be given prescriptions without being seen. The guidelines for all of these decisions are general and, unfortunately, what sometimes happens in practice is that these decisions are based on economic rather than medical factors.

Frequency of Visits

This depends on how stable the patient is and on how comfortable the health care professional is with the patient’s ability to adhere to the recommended regimen. If the patient is on a stable dose of medication and is doing well, then a visit every 1 to 2 months is generally considered reasonable. If the patient is on a relatively low dose of opioids, then 3 months is often adequate. If the patient has significant psychosocial issues, is a recovering addict, has exhibited difficulty with compliance, has a new additional pain issue, or the dose is being adjusted, etc., then the patient may need to be seen weekly, and, at times, there may even need to be telephone contact in between the visits.

Frequency of Physical Exams

Most guidelines do not specify how often a physical exam is required. Again, this depends on how stable the patient is and the provider’s comfort level. In my practice, on each visit vital signs are taken, and the patient’s gait (and other functions related to the patient’s specific pain problem) are observed and documented. The frequency of a detailed physical exam focuses on the diagnosis (not a comprehensive physical exam involving the entire body), depending on the patient’s stability. In my practice, (a pain specialty practice, not primary care), stable patients undergo a focused physical exam every 4 to 6 months. That being said, some states require a physical exam on every visit. But again, such rules do not specify the extent of the physical exam.

Frequency of Urine Drug Screens

Published guidelines do not specify a required frequency for UDS. Some prescribers routinely obtain a urine specimen from patients on every visit, which is not a useful approach. The goal of a UDS is to determine 1) whether a patient is taking controlled drugs as prescribed, and 2) whether the patient is taking controlled drugs that were not prescribed, and/or is using illegal drugs. Patients who expect to be asked to provide a urine specimen can prepare for it by researching how long prescription drugs and drugs of abuse stay in the urine, and by not using them in the days immediately preceding the appointment. And they can also make sure they have prescribed drugs in their body on the day of appointment. The point is, it is more useful to obtain random UDS. In my practice, UDSs are obtained 1) at random, 2 to 3 times a year, plus 2) any time I have any concerns about compliance. Patients do not know in advance when a urine sample would be requested.

Prescribing Without an Office Visit

Because insurance companies generally pay for only 30-day quantities of a medication and the Drug Enforcement Agency (DEA) does not permit Schedule II prescriptions to have any refills on them, the question arises about what to do for the second month (the month between appointments) for stable patients who medically need to be seen only every 2 months. Published guidelines do not mandate an office visit when a patient needs a prescription for a controlled substance. The DEA permits writing multiple prescriptions for Schedule II drugs for up to 90 days as long they are dated on the date they were written. Within the body of the second and subsequent prescriptions, write “Do not fill until . . . .” Pharmacists are not permitted to fill a prescription before that date. There are other circumstances when a patient may need a prescription without being seen—for instance, if a phone conversation results in the prescriber agreeing to increase the dose, the patient will need an early refill. It is certainly permissible for patients to pick up a prescription without being seen for an office visit, but it is important, of course, to document that the prescription was provided to the patient.

Review of Previous Office Visit

At the start of the visit, the clinician should review with the patient the plans documented in the record for the preceding office visit and the outcomes of each plan. Did the patient have any lab tests and imaging studies that were ordered? Are the results in the chart? Was a UDS done? Were the results “consistent” (ie, good)? If not, the clinician needs to determine and document whether the “inconsistent” results have a legitimate explanation (see Part 11) and, if not, what action was taken. Also, has the patient seen any specialist to whom he or she was referred, and, if not, is there a pending appointment? Have old records arrived? Is there anything in the record that needs to be discussed with the patient? If the medication regimen was changed, what was the result? Were there any new side effects? The information learned from the answers to these queries should be documented.

Documenting the “5 A’s”

An easy way to remember the elements necessary to ascertain and document at each follow-up visit is the “5 A’s.” These are based on the 4 A’s originally suggested by Passik and Weinreb2:

Last updated on: March 11, 2014
First published on: March 1, 2014