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.
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.
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.
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.