Home / Headlines / The Case for Scrupulous Documentation when Prescribing Opioids

The Case for Scrupulous Documentation when Prescribing Opioids

By Joseph M. Gorrell

opiodsOpioid abuse is becoming epidemic in the U.S., with more than 90 people dying each day of overdoses. A significant factor is the over-prescription of such pain medications as Oxycontin, Oxycodone and Fentanyl. Physicians who prescribe opioids must carefully weigh the pain relief benefits but also meticulously document medical care in compliance with increased regulatory oversight. Failure to do either could lead to sanctions against a physician’s license.

Written prescriptions must be preceded by an examination or evaluation of the patient and the name, strength and quantity of the medication should be contained in the medical record. Although the use of electronic medical records (EMR) in theory makes this documentation easier, issues around EMR system reliability and maintenance may impede the physician’s ability to comply with regulations.

Take the case of a physician who was suddenly faced with working alone due to one practice owner retiring abruptly and another out on disability. The practice’s EMR system did not function properly and having spent his entire career using paper records, this physician was not a facile EMR user; nor did he have the authority to spend practice funds to fix the system. This resulted in critical information that he’d gathered being excluded from the patients’ electronic medical records.

Joseph M. Gorrell

Since he prescribed a significant amount of opioids to manage many patients’ pain, and did not enter the information into the EMR system, the practice came under the scrutiny of the state licensing authority and the physician was called before an investigating committee. Subpoenaed patient records showed wide gaps in documentation—in spite of the physician obtaining complete histories and conducting thorough examinations.

Another pain management physician in the process of changing his EMR system vendor had prescribed a significant amount of opioids for patients suffering severe pain. When his state licensing authority subpoenaed patient records due to the quantity of opioids he was prescribing, this doctor was unable to produce the complete charts because in the EMR vendor transition, many progress notes and other medical record components had vanished. Due to this and other factors, the physician’s license has been temporarily suspended pending a full hearing.

Regardless of circumstances, it is the physicians who will be held responsible for breakdowns in documentation. Therefore, physicians should implement these documentation safeguards:

  • Monitor records and the EMR system on an ongoing basis to assure the system is working properly and that they are using it appropriately.
  • Remediate any problems immediately.
  • Educate themselves about their state licensing authority’s regulations regarding controlled dangerous substances to ensure compliance regarding prescribing and documentation.
  • Conduct audits of billing procedures to ensure that billing practices are appropriate.

Given today’s regulatory environment, physicians who prescribe opioids are well advised to follow all accepted medical practices and scrupulously document actions and prescriptions to avoid possible sanctions—taking extra care to properly implement and monitor EMR systems in their practices.


Joseph M. Gorrell is a member at Brach Eichler LLC, a law firm in Roseland, New Jersey. He can be reached at 973-403-3112 or jgorrell@bracheichler.com. (Photo by The Javorac via Flickr)


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