There is an old saying in real estate that the 3 most important features about a property for sale are “location, location, and location.” In medicine, an equivalent aphorism for the best way to avoid legal problems is “document, document, and document.” This is good advice in general but is especially important when prescribing opioids, an action that is increasingly subject to legal scrutiny.
When you first prescribe an opioid for a patient, it is important to document the following:
•Why you believe an opioid is indicated
•How you decided which opioid to prescribe
•How you determined the dosage
•If the patient has a history of substance abuse or you determine may be at increased risk of abusing an opioid, state your rationale for prescribing the medication. Also, document that you have discussed your concerns with the patient.
At every follow-up visit, document the following, as appropriate:
•How the patient is responding to the medication. The goal of treatment for chronic pain is two-fold: to reduce the level of pain and more importantly to improve function. Thus your record should note progress—or the lack thereof—in both of these areas.
•If the patient has not gained sufficient relief and you believe a medication switch is indicated, note why you chose the new opioid
•If the patient is requesting a different opioid before the previous prescription is dated to run out, note the reason for the request and how the balance of the original medication is handled. If you have the facilities to destroy the medication, ask the patient to bring to your office the remaining pills before a new prescription is provided. As an additional level of protection, ask a staff member to witness this step, and to document having done so in the chart (as part of your note). If you do not have the facilities to destroy the medication, ask the patient to return the unused medication to the pharmacy where it was purchased. Note that the new prescription is not to be filled unless the patient returns the unused medications.
•Discuss any concerns about medication use with the patient
Myths and Reality
Some physicians believe that the less they document, the lower their chances of encountering legal troubles. However, any lawyer or law enforcement official will confirm that this is a myth. The more extensive your documentation, the less likely you are to have problems.
Keeping good records is time consuming and most physicians in fee-for-service practice today would prefer to use this time to see patients and earn a living. However, we would be wise to take a page from our medical training and observe the preventive measures that can keep us in our offices and out of the courtroom.