Quality statement 7 - Documentation

When a patient with acute pain is prescribed, supplied or administered an opioid analgesic, the intended duration of therapy, and the review and referral plan are documented in the patient’s healthcare record. The cause of the pain for which the opioid analgesic is prescribed is documented, including on the inpatient prescription.

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Purpose

To improve documentation of opioid analgesic therapy to support effective communication among clinicians and patient understanding through the patient’s healthcare record and the inpatient prescription. Documentation allows the appropriateness of the prescription to be assessed, and ensures that all clinicians involved in the patient’s care have access to consistent and current information.

For consumers

Your healthcare record contains information about your opioid analgesic therapy. This includes information on:

  • The medicine (active ingredient/s) and dose you have been prescribed
  • The cause of the pain for which the opioid analgesic is prescribed
  • How long to use them for
  • The plan to review your opioid analgesic treatment
  • The plan to reduce the opioid analgesic medication, to allow you to stop taking the medicine.

Information in your healthcare record can help different clinicians involved in your care to understand why an opioid analgesic has been prescribed and the plan for your care.

For clinicians

When prescribing opioid analgesics, document the indication, intended duration (number of days), the review and referral plan, and the weaning and cessation plan in the patient’s healthcare record. This documentation includes the patient’s paper or electronic medical record, the My Health Record system, prescription record, medication chart and medication management plan.

Document the cause of pain for which the opioid analgesic is prescribed, including on the inpatient prescription, to ensure the reason for use of the opioid analgesic is printed on any dispensed opioid analgesic the patient takes with them when they leave hospital.

Document co-prescribed paracetamol, non-steroidal anti-inflammatories or nonpharmacological treatments, in the patient’s healthcare record.

For health service organisations

Ensure a system is in place for clinicians to document the intended duration (number of days), the weaning and cessation plan, and the review and referral plan for opioid analgesics in the patient’s healthcare record.

Ensure a system is in place for clinicians to document the cause of pain for which the opioid analgesic is prescribed, including on the inpatient prescription.

Where electronic medical records are being used, incorporate flags and reminders into the record management system to support documentation in all relevant fields or consider making them mandatory fields.

For consumers

Your healthcare record contains information about your opioid analgesic therapy. This includes information on:

  • The medicine (active ingredient/s) and dose you have been prescribed
  • The cause of the pain for which the opioid analgesic is prescribed
  • How long to use them for
  • The plan to review your opioid analgesic treatment
  • The plan to reduce the opioid analgesic medication, to allow you to stop taking the medicine.

Information in your healthcare record can help different clinicians involved in your care to understand why an opioid analgesic has been prescribed and the plan for your care.

For clinicians

When prescribing opioid analgesics, document the indication, intended duration (number of days), the review and referral plan, and the weaning and cessation plan in the patient’s healthcare record. This documentation includes the patient’s paper or electronic medical record, the My Health Record system, prescription record, medication chart and medication management plan.

Document the cause of pain for which the opioid analgesic is prescribed, including on the inpatient prescription, to ensure the reason for use of the opioid analgesic is printed on any dispensed opioid analgesic the patient takes with them when they leave hospital.

Document co-prescribed paracetamol, non-steroidal anti-inflammatories or nonpharmacological treatments, in the patient’s healthcare record.

For health service organisations

Ensure a system is in place for clinicians to document the intended duration (number of days), the weaning and cessation plan, and the review and referral plan for opioid analgesics in the patient’s healthcare record.

Ensure a system is in place for clinicians to document the cause of pain for which the opioid analgesic is prescribed, including on the inpatient prescription.

Where electronic medical records are being used, incorporate flags and reminders into the record management system to support documentation in all relevant fields or consider making them mandatory fields.

Read Quality statement 8 - Review of therapy

Related links
Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard
Quality Statements - Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard
Topics
Clinical Care Standards
Medication safety
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