With opioid addiction officially a public health emergency in the United States, it’s more important than ever that physicians and other clinicians carefully document a patient’s opioid use in the electronic health record.
To help providers better document the use and abuse of opioids, the American Health Information Management Association (AHIMA) has created an opioid addiction documentation tip sheet that gives examples of proper documentation that complies with the seven characteristics of high-quality clinical documentation. Those factors include providing clear, precise, complete information.
AHIMA spokesperson Mary Jo Contino said proper documentation and EHR interoperability is often overlooked as a tactic to help reverse the country’s opioid epidemic. Fewer than 30% of health system EHRs are fully interoperable, and less than 20% actually use data transferred from another provider, according to a new study.
It’s important that physicians and other healthcare providers accurately record information in the EHR when an individual using or abusing opioids visits their office. Without national communication standards for health information exchange, that documentation is often not shared among healthcare system facilities or across state lines, allowing people with addictions to seek opioids from multiple physicians.
Meanwhile, Prescription Drug Monitoring Programs (PDMPs) are gaining traction as opioid overdose deaths have skyrocketed. Last month, the President's Commission on Combating Drug Addiction and the Opioid Crisis recommended state and federal PDMPs be interoperable within 12 months.
The tip sheet lists the seven characteristics of quality documentation, provides scenarios of how to meet the criteria and provides an example of poor documentation frequently seen when treating patients with opioid prescriptions. The tip sheet also has examples of a proper documentation statement.
Last month, President Donald Trump declared the opioid epidemic a national public health emergency. AHIMA says high-quality clinical documentation will guarantee that the data which drives research and education about opioid addiction is based on correct information.