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 (3 votes)
Tags:
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.
Tags:
Medical Recordkeeping
