RECORD KEEPING

It is important to keep accurate medical records that reflect the complexity of diagnosis and treatment planning for patients with pain disorders. These should reflect a well maintained medication list, up to date diagnoses, systems review, examination documentation, interim history, and treatment planning.

A separate area of sequential schedule 2 prescriptions should be kept if using these medications. This can be quite helpful in looking at trends in medication dosage, frequency of refills and patterns of medication usage.

Clear records are also helpful for medical legal issues that may arise. A clear description and sequential treatment plan are very useful in deposition and court testimony. Additionally good medical records are an advantage for submission of information for Social Security Disability or private disability evaluations. Organized record keeping is also necessary to deal with Medicare audits.

The most important reason to keep careful records is to maintain excellent patient care. For a pain practice it is important to be able to review treatments that have been tried to determine whether new treatments should be instituted or old treatments should be tried in combination with newer approaches. Along these lines, notes that are consistent in style and structure are most helpful. Coming up with a routine set of categories to evaluate at each patient visit and documenting this routine in the medical record is an essential step in the process of keeping good records. Whether notes are written by hand, typed on a computer or dictated, consistency is a necessary factor in maintaining high quality medical records.