Anesthesia Management: Pain Clinic Documentation Requirements

Pain physicians need consistent and efficient methods to document their interaction with and treatment of patients.

Here is a Documentation Checklist:

1) The pt’s medical history both general and pain specific  along with the Physical exam findings

2) If you have a physical exam from another practitioner then list any impressions concerning your review of another practitioner’s report of their physical exam

3) All diagnostic results related to the painful condition

4) A written treatment plan stating the pt’s subjective pain goals and agreed upon treatment objectives

5) Informed consent especially if it involves the risk and benefits of opioid therapy along with treatment alternatives.

6) All treatments order and completed and treatment results along with all medicines prescribed including dates, types, dosage and quantity given. Include pt monitoring information including pill counts and drug screens.

7) All treatment related information given to the pt and the pt’s responds and any questions answered

8) Pt treatment agreements and accountability forms

9) Reports of follow up visits including excuses and stories about pain medications and discharge documentation if applicable.