Opioid Rx Charting
How to determine when you initiate or continue opioids for patients with chronic pain: What kind of pain is it? Is it a nerve pain, a throbbing pain or a arthritic type of pain? And if it’s arthritic; what kind of arthritis? Psoriatic, rheumatoid, gouty, or degenerative? Was it due to a sprain, or a strain that caused the arthritic pain? Or was it trauma, such an automobile accident? If so, please go into detail as to the mechanism of the accident. That is of the utmost importance in substantiating your treatment plan. Your medical records should always have a treatment plan in place. They are some states require a written treatment plan if you are using controlled substances for a certain period of time.
What exacerbates or triggers the pain? Extension, flexion, inversion, or eversion? Please conduct a range of motion test, find the pain point to determine if or when does the pain becomes intolerable? Is this type of treatment done on each visit as the patient is healing? If so, I am very pleased you are doing that already; but does your record reflect that?