Medical Recordkeeping Guidelines for Substance Abuse Patients

In addition to the specific federal recordkeeping guidelines for buprenorphine patients, it is recommended that you document the following information:

History and Current Status

  • Initial diagnosis and treatment plan information
  • History and physical examination
  • Comparisons with initial presentation
  • Assessment of pharmacological efficacy
  • Lab tests and results
  • Compliance with treatment plan
  • Urine and blood drug screening
  • Medications prescribed
  • Dispensing of controlled substances

Treatment Plan

  • Diagnoses and how determined
  • Treatment goals
  • Determination of medication to be used
  • How medication will be used
  • Psychosocial services required/recommended

Other Information

Additionally, physicians with an office-based buprenorphine practice may want to keep track of the following:

  • Patient payment information (useful for fee-for-service practices)
  • Induction, maintenance, discontinuation, and discharge information
  • Instances of patient non-compliance and subsequent actions taken

Keeping the above information complete and organized will be useful if a patient relapses and then returns to treatment or when a referral is needed.



Related Resources: 
Description: 
This checklist provides a list of the forms that must be signed, the information that should be recorded for each patient (including current medications and allergies), and tests and labs that should be drawn during the intake assessment.
Source: 
Colleen LaBelle, RN/Boston Medical Center
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Medical Recordkeeping

Description: 
A description of what should be included in a buprenorphine patient's medical record.

Many portions of the medical record contain general information that is not specific to patients with substance use disorders or opioid dependence. An example of this is the history portion of the record.

The following sections of the medical record should be noted for all substance use patients:

  • Initial diagnosis and treatment plan information
  • History and physical examination
  • Comparisons with initial presentation
  • Assessment of pharmacological efficacy
  • Lab tests and results
  • Compliance with treatment plan
  • Urine and blood drug screening
  • Medications prescribed
  • Dispensing of controlled substances

Treatment Plan

The treatment plan portion of the medical record should be a natural continuation of the previous portions of the medical record. The following information should be carefully documented and shared with the patient:

  • Diagnoses and how determined
  • Treatment goals
  • Determination of medication to be used
  • How medication will be used
  • Psychosocial services required/recommended

When the practitioner reviews this information with the patient, he/she should include the patient in formulation of treatment goals. Following the patient-practitioner review, both parties should sign and date the information contained in the treatment plan. Information about buprenorphine -- such as its effects, what to expect, and what not to expect -- should be discussed with the patient, and this discussion should be documented as well. The practitioner must remember to put his or her DEA registration number on the patient's medical records, as well as the patient's prescriptions.

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