The Devil is in the Details: Patient Medical Record Requirements when Treating for Chronic Pain

Samuel E. Pondrom | 4.13.17

On August 4, 2015, the Texas Medical Board (TMB) amended Title 22, Section 170.3 of the Texas Administrative Code (TAC) to combat pill-mills.  While these changes were both necessary and laudable considering the U.S.’ escalating opioid abuse epidemic, the practical (and unavoidable) consequence is that strict compliance with the law becomes more difficult for good and bad actors alike.

Section 170.3, now entitled “Minimum Requirements for the Treatment of Chronic Pain,” requires physicians to carefully document specific data during the evaluation, treatment, and periodic review of a patient’s chronic pain. Critics caution that it may punish physicians who use their sound professional judgment and rationale in prescribing drugs for chronic pain, but fail to meet the detailed recordkeeping requirements of the updated regulation.  In fact, Section 170.3 sets forth 10 items the medical record must reflect to properly document the physicians rationale including: the patient’s (1) medical history and physical examination; (2) diagnostic, therapeutic, and laboratory results; (3) evaluations and consultations; (4) treatment objectives; (5) discussion of risks and benefits; (6) informed consent; (7) treatments; (8) medications (including date, type, dosage and quantity prescribed); (9) instructions and agreements; and (10) periodic reviews.  An otherwise competent physician who fails to carefully document all of these items could be subject to TMB discipline.

Even where Section 170.3 calls for prescribing physicians to use their judgment, strict documentation is required.  For example, physicians are required to “consider” consultations and referrals to experts for certain at-risk patients.  Moreover, physicians must “consider” reviewing patient prescription data contained in the Prescription Drug Monitoring Program and obtaining a toxicology drug screen.  However, if a physician decides not perform these tasks, they must document in the medical record their rationale for not doing so.

The good news is that while these documentation requirements are somewhat cumbersome, simply being aware of the new requirements and updating your policies and procedures accordingly is half of the compliance battle.  The other half, unfortunately, is keeping meticulously detailed medical records when treating a patient’s chronic pain.

If you have any questions on the minimum requirements or if you would like your policies and procedures for the treatment of chronic pain reviewed, please contract Jay D. Reyero (jreyero@byrdadatto.com) or Bradford E. Adatto (badatto@byrdadatto.com).Medical Record Image