Nurses have an important role to play in keeping medical records complete and accurate. Patient medical records should remain current and be accessible for review, and should include the following:
- Copies of the signed informed consent and treatment agreement
- The patient’s medical history
- Results of the physical examination and all laboratory tests
- Results of the risk assessment, including results of any screening instruments used
- A description of the treatments provided, including all medications prescribed or administered (including the date, type, dose, and quantity)
- Instructions to the patient, including discussions of risks and benefits with the patient and any significant others
- Results of ongoing monitoring of patient progress (or lack of progress) in terms of pain management and functional improvement
- Notes on evaluations by and consultations with specialists
- Results of queries to the state PDMP
- Any other information used to support the initiation, continuation, revision, or termination of treatment and the steps taken in response to any aberrant medication use behaviors. These may include actual copies of, or references to, medical records of past hospitalizations or treatments by other providers
- Authorization for release of information to other treatment providers (FSMB, 2017)
The medical record must include all prescription orders for opioid analgesics and other controlled substances, whether written or telephoned. In addition, written instructions for the use of all medications should be given to the patient and documented in the record.
The name, telephone number, and address of the patient’s primary pharmacy should also be recorded to facilitate contact as needed. Records should be up to date and maintained in an accessible manner so as to be readily available for review (FSMB, 2017).
Referral to Pain Management Specialists
Clinicians should be willing to refer patients to pain management specialists if they are uncertain about the pain diagnosis or the prescribing, monitoring, or discontinuing of opioid analgesics for patient pain. CDC guidelines recommend caution when prescribing 50 mg or more morphine equivalents a day and avoiding 90 mg or more (CDC, 2017b). Referral of patients hitting these thresholds may be advisable because these thresholds indicate greater risk and may indicate a failure of opioids to achieve functional goals. Patients who need a procedure or surgery may need a referral to a pain specialist. Primary care and pain specialists should foster good communication. This encourages collaboration on what may be a challenging patient population. Collaboration includes sharing medical records, jointly determining treatment plans, and care coordination (AAPM, 2016).
Discontinuation of Opioids
If the patient experiences a resolution of the underlying painful condition then opioid analgesics should be discontinued. Discontinuing opioid therapy is also appropriate if there is a lack of therapeutic effectiveness or if risk increases. Also, if the patient reports continued severe pain despite a trial of several different opioids, and experiences no functional improvement, discontinuing the opioid therapy by careful, safe tapering is indicated (FSMB, 2017).
Another reason to taper is if the patient is experiencing unmanageable adverse side effects, complications such as depressed mood, sleep apnea, sedation, or is displaying aberrant drug-related behavior or signs of addiction, or fails to comply with the treatment agreement despite a reasonable dose.
Clinicians must exercise the following precautions in tapering opioids:
- Tapering decisions must be made on an individual basis.
- Clear, written and verbal instructions should be given to patients and their families to educate them about tapering and to minimize withdrawal symptoms.
- Be prepared to provide supportive counseling and frequent (weekly) follow-up visits. Ask about pain, withdrawal symptoms, and any beneficial effects of the tapering, such as improved mood, energy level and alertness and decreased pain.
- Prepare a detailed tapering plan, including type of opioid, scheduled doses, and a frequent dispensing schedule.
- Switch to morphine if the patient is dependent on hydromorphone or oxycodone.
- Use slow tapering for patients who have cardio-respiratory conditions.
- Adjust dose up or down as necessary to relieve withdrawal symptoms without inducing sedation.
- Refer patients with complicated withdrawal symptoms to a pain specialist or a medical center that specializes in treating withdrawal.
- Refer patients with opioid addiction for substance abuse disorder treatment. Addiction is best managed by opioid agonist treatment such as methadone or buprenorphine. (VA/DoD, 2017; SAMHSA, 2018; FSMB, 2017; WVMB, 2017)