Innovations In Clinical Neuroscience

MAR-APR 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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R I S K M A N A G E M E N T 49 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE March-April 2018 • Volume 15 • Number 3–4 • Prohibiting early or urgent refills • Prohibiting the replacement of lost or stolen prescriptions • Prohibiting dose or frequency increases unless prescribed by physician • Using the state PMP • Performing random pill counts • Performing random drug screening Treatment agreements. Treatment agreements are useful for managing patient expectations. Some states require treatment agreements, typically for pain management, but prescribers might want to consider incorporating treatment agreements into their practice, even if they're not legally required (Appendix 2). Communicating with others . Other providers. Consultation with colleagues is a valuable clinical and risk management approach. Obtaining consultation tends to support thoughtful decision-making, demonstrate objectivity in the choice of treatment modalities, and might provide some assurance that the quality of care delivered meets the standard of care. It is also important to communicate with other providers involved in the patient's care, such as covering physicians and other treaters. Family members/significant others. Communication with family members as authorized by the patient can be useful in keeping the patient adherent and safe. In emergency situations, remember that safety of the patient or others is an exception to confidentiality, so no authorization is required. Also, remember that listening to others, without confirming the person is a patient, is not a breach of confidentiality and might yield clinically significant information. You can listen to third parties without breaching patient confidentiality as long as you are not disclosing information. RISK MANAGEMENT STRATEGY #3— CAREFULLY DOCUMENTING The primary purpose of the medical record is for continuity of care, thus your records should be written so that a subsequent treatment provider can review the record, know what happened in treatment, and why. For example, documentation of your decision-making process can include diagnosis, medication choice, why this medication was chosen for this patient, and why a dosage was changed. Often, information about clinical actions not taken is as important as information about actions that were taken. Careful documentation provides subsequent readers with information about the basis for your clinical decisions and is critical to the ongoing care of patients. It also supports that you exercised thoughtful professional judgment should your treatment decisions ever be questioned by expert witnesses in litigation, by the regulators, or by yourself years later. Consider including the following in your records: • Initial evaluation • Medical indication for prescriptions • Medication log - Name of medication - Start and stop dates - Changes in dosages • Treatment plan—initial and updated • Informed consent—including patient education materials • Assessment forms, if used. • Ongoing patient assessment - Adherence to treatment plan - Medication monitoring - Laboratory testing ordered and results reviewed - Aberrant behavior - Results of PMP queries (Note: Given the strict confidentiality requirements related to these PMP reports, you should not include the actual PMP report in your record unless it is required by the state. Rather, document that the query was done and what (if any) actions were taken based on that report.) • Referral/consultation, if necessary CONCLUSION Using the three Cs of risk management strategies—collecting information, communicating, and carefully documenting— when prescribing controlled substances supports quality patient care and can decrease the risk of improper prescribing allegations. APPENDIX 1. PRESCRIBING CONTROLLED SUBSTANCES: INFORMED CONSENT Some, but not all states have promulgated various requirements and recommendations for components of an informed consent discussion when prescribing controlled substances. The following is a compilation of current individual state requirements and recommendations for informed consent. Prescribers should determine the state requirements for their state, and may want to consider incorporating these components: • The physician shall obtain written, informed consent and discuss the risks and benefits of the use of controlled substances with the patient; persons designated by the patient; or the patient's surrogate or guardian if the patient is incompetent. • Ensure the patient does not have any absolute contraindications and review risks and benefits related to any relative contraindications with the patient. • The treatment plan, any alternatives to controlled substance therapy, additional therapies to be used in conjunction with controlled substances (if any) should be reviewed. • Inform the patient of the risks of addiction, physical dependence, and abuse; the potential for dose escalation/tolerance. • Inform the patient of the risk of the prescribed medication interacting with other drugs and of over-sedation. • Inform the patient of potential side effects (short- and long-term) of the prescribed medication. • Inform the patient of the risks of impaired motor skills that affect driving among other tasks and the potential for impairment of judgment. • Inform female patients of the risks during pregnancy and after delivery.

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