How Should You Document Opioids in Your EHR?

Opioid abuse is rampant and physicians are being held accountable for drugs prescribed by the federal government.

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The American Health Information Management Association (AHIMA) put together a sheet of helpful tips for physicians to consider when documenting opioids in electronic health records (EHRs).

The opioid crisis continues to be a serious nationwide problem.

In Michigan alone in 2016, there were 2,335 deaths from drug overdoses.

In 2015 in Michigan, according to data from the Michigan Automated Prescription System (MAPS), there were 11.4 million prescriptions written for painkillers. That is about 115 prescriptions per 100 people.

Many physicians are worried about having their medical decision making scrutinized by the federal government.

So how can you help your practice avoid scrutiny and avoid potential issues with your prescriptions?

It comes down to your documentation.

The cheat sheet that AHIMA released indicated that documentation regarding opioid addiction should be:

  • Clear,
  • Consistent,
  • Complete,
  • Reliable,
  • Precise,
  • Legible, and
  • Timely.

The cheat sheet offers examples of poor quality and high quality documentation.

EHRs allow for better tracking are reporting of drug use and abuse.

What do you think of AHIMA’s tips for EHR documentation? Does your practice already emphasize clear, consistent, and legible documentation?

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