Proper and complete medical record reflects the quality of the care provided by the physicians to his patients. From the medicolegal perspective, medical documentation is essential while managing chronic pain patients. The current article describes the key documentation points while prescribing opioids in the chronic pain patients. Pain is the most common reason for all the hospital visits in India.
Although physicians spend a lot of their time in diagnosing the type of pain, its intensity, etc., they lack in spending time on pain-related documentation. Opioids documentation in chronic pain patients is important to assess the clinical improvement in the patients and to avoid medico-legal issues. Following is the list of elements that should be documented at the time of the initial workup of the patient. Initial work-up documentation A complete Medical, medication and social history of…
