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11 Articles in this Series
A PAINWeek 2019 preview with EVP Debra Weiner
Comparing Marijuana and Hemp
Fibromyalgia: What’s New in Diagnosis and Pain Management
Life Hacks to Teach Patients with Chronic Pain
Managing Pain (and Function) in Osteoarthritis: Are Patients and Physicians on the Same Page?
Marijuana: How to Proceed When Controlled Substances are Involved
Menopause Comes with More than Mood Swings - It Deserves its Place Among Chronic Pain Conditions
More APPs Are Coming to the Forefront of Pain Care
Motivational Interviewing and Its Extension into Pain Management
Revisiting Documentation
Side Chat: Modern Analgesic Trials

Revisiting Documentation

Most providers have a handle on what to keep on file when it comes to patient charts. Here are a few more points to consider to ensure your record-keeping is up to par. A Q&A with Michael C. Barnes, JD

Michael C. Barnes, JD, is managing partner and founder of DCBA Law and Policy in Washington, DC. The firm has been nationally recognized for its work on pain management, addiction treatment, and controlled medications, including opioids. In 2018, Barnes, along with Lynn Webster, MD, offered providers some practical advice for navigating opioid prescribing requirements, including how a practitioner may protect him or herself from federal scrutiny with thorough documentation, patient engagement, and consultation. Here, Barnes shares with PPM a few additional—yet unexpected—tactics that clinicians should keep in mind when updating charts and conversing with patients.


PPM: Providers are typically apt at documenting patient symptoms, treatment plans, and compliance. What more should they consider when it comes to proving/documenting legitimate medical need for a particular prescription, and that they took reasonable steps to prevent harm?

Barnes: To protect oneself from criminal or civil liability, a prescriber of controlled medications should establish and document thoroughly that the patient has a legitimate medical need, the treatment plan is consistent with the ordinary course of professional practice, and the prescriber has taken reasonable steps to prevent harm to the patient and community.

In the midst of a nationwide “crackdown” on opioid prescribing, any patient could be an undercover law enforcement officer or informant. Healthcare providers must be certain and document in the medical record that a patient with purported chronic pain has tried and not adequately benefited from lower-risk interventions, such as non-pharmacological, non-controlled, and lower-scheduled pharmacological treatments, before prescribing higher-scheduled opioid pain relievers. For new patients, third-party evidence, such as medical records from a previous healthcare provider or a PDMP report, is essential to proving the patient has tried and not succeeded on lower-risk treatments.

In preventing harm to the patient and community, prescribers of opioid pain relievers should take precautions such as PDMP data checks, urine drug testing, and pill counts, but they should not stop there. They should document their findings and detail with specifics how they addressed any problems they identified.


PPM: A common recommendation is for prescribers to ask themselves, “How is this treatment making the patient’s life better?” This is key for every patient visit. Can you explain why?

Barnes: Whether appropriate or not, prescribers of opioids for pain are being scrutinized against the CDC Guideline for Prescribing Opioids for Chronic Pain in primary care settings. Recommendation 1 of that guideline is to initiate or continue opioids for chronic pain only if the benefits for both pain and function outweigh the risks to the patient. Documenting how treatment with opioids is making the life of a patient with chronic pain better can provide evidence that the benefits exceed the risks of the treatment.

The prescriber’s notes should take into account pain relief and improved function, as well as treatment efficacy and adverse events. Obviously, if the treatment is not making the patient’s life better, then the treatment plan should be adjusted, updated in the medical record, and monitored carefully.


PPM: More and more, providers are being encouraged to have a “full narrative” of their patients documented in a way that enables them to tell the whole story on the stand in court if necessary. What’s one way to approach this?

Barnes: Confidentially discussing with a patient his or her family, work, and social life can help to reduce risks to both the patient and the healthcare provider. Details of this nature can help a pain management practitioner assess and counsel the patient on the risks of a particular treatment, customize a treatment plan, evaluate treatment efficacy, and gauge functional improvements.

A record of such information can help to refresh the practitioner’s memory of the patient and his or her medical needs, treatment plan, and outcomes as part of a licensing-board or judicial defense. The ability to connect the course of treatment with the unique needs of the patient can make or break a healthcare provider’s livelihood and liberty.


PPM: You have noted that all healthcare decisions should be citable to credible literature/practice standards. Why?

Barnes: In the legal setting, judges and juries assess facts against rules. The rules that apply to healthcare treatment are set forth in government recommendations, FDA-approved prescribing information, professional associations’ guidelines, the medical literature, and in worst-case scenarios, the testimony of expert witnesses.

In creating a medical record, a provider should document all of the patient-specific facts necessary to establish that a credible, current rule or exception covers the patient’s scenario. He or she should know or otherwise document in the medical record the source of the applicable rule or exception. Finally, the practitioner should document that he or she followed that rule or exception in directing and communicating the patient’s treatment plan.

Following this approach should make it very difficult for an expert witness working for a prosecutor or plaintiff to make a convincing case that the practitioner’s conduct was inconsistent with the standard of care.




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