Proper Chart Documentation is Essential for Managing Chronic Pain Patients

Proper Chart Documentation is Essential for Managing Chronic Pain Patients When it comes to managing patients with chronic pain, inadequate documentation can affect care and even attract regulatory scrutiny.

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Proper clinical documentation is essential in any medical specialty. However, efficient chart documentation is especially critical for managing patients with chronic pain. When it comes to treatment of chronic pain patients with opioids, an article in Practical Pain Management points out that inadequate documentation can attract regulatory scrutiny and is a very common reason for medical board discipline.

Chronic pain is defined as pain that lasts longer than three to six months. A complex condition, it is difficult to diagnose, evaluate, and manage. Chronic pain can be nociceptive, neuropathic, mechanical, or mixed in origin. Moreover, symptoms are subjective in nature, with patients presenting in various ways. All of these issues contribute to the complexity of managing chronic pain. Proper documentation of pain assessment and the treatment plan allows multiple healthcare providers to communicate effectively and facilitate effective pain management and better patient outcomes. The Practical Pain Management article lists the documentation essentials for chronic pain patients with opioids as follows: -

Initial evaluation

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Follow-up office visits

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Urine drug screens

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An up-to-date medication chart

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Phone calls, emails, and communications with family

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Initial office visit: During the first visit, the provider should record information about the history of the problem, physical exam, the type and intensity of the pain, previous diagnostic test results, and treatments. The documentation should also list the types, doses and durations of medications given in the past, and the reason for discontinuing a particular medication. The medical record should include the patient’s psychological and social circumstances, such as whether they live alone, whether they are employed, whether they have depression, anxiety, and other psychiatric problems. Risk for drug abuse or diversion should also be assessed.

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Urine drug screen (UDS) results: Getting a baseline UDS done is recommended if the patient is taking prescription opioids or if the physician is considering opioids as part of the treatment plan. When the UDS is ordered, the time of the last dose of the drug should be documented. Results of the test should be reviewed and observations

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should be documented, including actions on any unexpected results. Results should be discussed with the patient’s toxicologist to verify whether the unexpected drug in the urine is a legitimate metabolite of a prescribed drug or not.

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Prescription monitoring: All providers have access to the Prescription Monitoring Program (PMP), an updated list of all controlled substances prescribed to each patient in that state. Providers should document in the patient’s chart that they have checked the patient’s history on the website and if there are results of any concern.

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Documentation of treatment plan and goals:

Specific, measurable goals of

treatment, including the specific areas of improvement in function should be discussed with the patient. Documentation should include prescriptions, referrals, lab and imaging tests, physical therapy, etc., as well as the discussions with the patient.

The physician should explain thinking and decision-making, and not simply check the boxes given in the EMR system. Copying and pasting should be avoided as it can affect the credibility of the record.

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Follow-up visit: The plans documented in the record for the preceding office visit and the outcomes of each plan should be reviewed with the patient. If results of tests were inconsistent (not good), the clinician should document the reason for this and action taken. Adhering to the following 5 A’s is a best practice to ensure proper documentation at the follow-up visit:

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Analgesia: The level of pain (on a scale of 1 to 10)

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Activities of daily living: Specific information on what the patient does (e.g., takes a 20 minute walk)

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Adverse effects due to medication

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Aberrant drug-related behaviors

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Affect—the patient’s mood, as depression and anxiety worsen pain

The medical record is the basis for providing patient care. However, as a report from the American Society of Regional Anesthesia and Pain Medicine notes, many surveys have shown that the documentation requirements of EHRs are driving physician burnout and early retirement and even affecting the quality of care. Delegation is an effective solution for this problem. Pain physicians can free up time for tasks that require their expertise by delegating the documentation task to medical scribes. In fact, many physicians have

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reported improvements in their interactions with patients and increased work satisfaction with the use of scribes.

Medical transcription outsourcing is another proven strategy to ensure proper pain management documentation. Experienced companies provide accurate and timely EMRintegrated pain management transcription service, allowing physicians could leverage the power of patient data to improve care.

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