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What are ACP's expectations for documentation? Part 5 of our opioid guidelines series

September 14, 2017

The October 1, 2017, implementation date for the Guidance for Assessment and Monitoring: Individuals using Opioid Medications is rapidly approaching. Something pharmacy professionals should consider is the pharmacy’s process for documenting assessments and developing treatment plans for individuals. These expectations are outlined in the guidance document:

Pharmacists must document details of the assessment in the patient record of care and develop a written treatment plan for individuals using long term opioid therapy or for those determined to be at high risk of misuse or addiction.

What must be documented?

Standard 18 and Appendix A of the Standards of Practice for Pharmacists and Pharmacy Technicians provides direction on this but, from a more pragmatic point of view, think about what information you would like to see when you check a patient’s profile. When you are assessing opioid therapy, information such as previous requests for early refills, refusals to fill, communications with the prescriber, drug-related problems, and notes on initial assessment and progress can be invaluable in making treatment decisions.

A great documentation resource on the ACP website is the prescribed activity: Documenting Patient Care on the ACP Continuing Professional Development Portal. RxA offers an online course Care Plans in Alberta: Developing Your Patient Care Process that provides valuable information not only on creating care plans, but on general documentation as well.

Who requires a written treatment plan?

All opioid prescriptions must be assessed and the assessment documented as noted above. In addition, individuals using long term opioid therapy or those using acute opioid therapy that you determine to be at high risk of addiction or misuse, require a written treatment plan. Thus, an opioid naïve patient receiving a small amount of an opioid medication for an acute condition like a dental extraction may not require a full written treatment plan, unless your assessment identifies concerns with addiction or misuse.

What does a treatment plan look like?

A treatment plan does not necessarily need to be long and complex. It can be as simple as a DAP note and, at minimum:

  • must identify the indication for the opioid;
  • must establish baseline data and identify parameters to monitor such as: pain and function, drug related problems, adherence and signs of misuse or addiction;
  • must specify appropriate timeframes for monitoring and follow up and identify who will conduct the reassessment;
  • must ensure that a documented record of care is created that includes a record of all collaborations, interventions and assessments performed by the pharmacist. This record should be created in a way that is easily retrievable and is consistent among the pharmacy team members.

Tip: If a treatment/care plan has already been completed by the prescriber or another healthcare professional, you can just adapt it for your own use. Ensure it has all the information you require and modify as necessary. This approach encourages both consistency and collaboration.

How do I document this?

Many pharmacies already use a standardized worksheet as the basis for assessment and documentation of injections. Consider adopting a similar process using worksheets specific to opioid therapy. There are many validated tools available for pharmacists to use such as:

These documents or ones like them can be used alone or in combination as required to fit the needs of your pharmacy.

Tip: Ensure you allow yourself enough time to assess and document prescriptions for patients using opioid medications, especially when you are first developing your process.

Pharmacy professionals practice in different practice environments with varying software systems. This makes a one-size-fits-all approach difficult and every pharmacy team must decide for themselves what a treatment plan should look like for their pharmacy. When you review your current processes, you may find that you are already doing much of this work already.

Tip: Many of these individuals may qualify for, or have an existing formalized care plan in place already. For these patients, the opioid assessment and documentation can easily be integrated into this process.

In developing the treatment plan, the pharmacy team should consider:

  • Where is the easiest place to document that will be consistent among all staff and readily retrievable at future encounters?
  • Are there existing systems in place that can be adapted to accommodate these plans?

Remember, the real goal here is not to simply meet a standard, but rather to develop processes for your practice that work for you and your patient to optimize therapy, prevent adverse drug events, and minimize harm.

To further help integrate these new guidelines into practice, ACP will be adding links to tools, articles, and other resources on our website to provide you with the support you need. Watch for an announcement on this in the coming weeks!

 Read the guidance

Originally published in the September 13, 2017, issue of The Link


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