AHIMA: Here's how hospitals should document opioid abuse in the EHR
As the U.S. takes aim at the opioid crisis, the American Health Information Management Association has put together a tip sheet to help clinicians better document how their patients are using these dangerous drugs.
Patients' use or abuse opioids is documented in their electronic health records, but how easily that data can be used by other providers across the care continuum could play a big role in how those patients are treated.
"There are seven characteristics of high-quality clinical documentation. If a provider learns how to document using these characteristics to guide their documentation habits, they will provide trustworthy documentation," the group said.
Those characteristics that best define optimal EHR charting are: clear, consistent, complete, reliable, precise, legible and timely.
We've already seen an array of technology-focused interventions, from better cybersecurity protections for e-prescribing of controlled substances to smart caps and automated pill dispensers to help prevent the doctor shopping and overuse that fuel the opioid epidemic. But clinical documentation improvement and interoperability have crucial roles to play.
AHIMA's Opioid Addiction Documentation Tip Sheet lays out those characteristics alongside hypothetical examples of what clinical documentation for potential opioid abusers would look like if they were – or weren't – followed.
With unclear charting, for instance, symptoms are documented without a clarification of a supporting diagnosis. Inconsistent documentation can sometimes be conflicting. When it's incomplete, abnormal findings are noted without an associated condition.
Unreliable EHR data might show a given treatment provided without a documented condition. Imprecise records are unclear on a given diagnosis. Illegible notes can be difficult to decipher. Untimely documentation is asynchronous with the time care is being delivered.
For example of the importance of clarity, AHIMA points out that a doctor might write, "27-year-old male admitted with lethargy. History of drug use."
But why was the patient lethargic? A more useful and potentially life-saving way to make the note would be "27-year-old male admitted with lethargy due to opioid dependency and overdose."
With regard to completeness, AHIMA offers another example of a note that could be better: "42-year-old female admitted for somnolence and abnormal drug screening." Again, why? What is the diagnosis that supports that? A better note would read "42-year-old female admitted with drug dependence and intoxication of Oxycodone as evidenced by positive drug screen for opioids."
Any one of those less-than-ideal characteristics – let alone several at once – can lear to a patient record that doesn't tell the whole story, or doesn't tell it accurately. As the suboptimal notes increase, so do the chances that signs of opioid dependency could be missed, especially as the patient moves from provider to provider.