Recordkeeping

In addition to the specific federal recordkeeping guidelines for buprenorphine patients, it is recommended that you document the following information:

Related Resources: 
Description: 
This checklist provides a list of the forms that must be signed, the information that should be recorded for each patient (including current medications and allergies), and tests and labs that should be drawn during the intake assessment.
Source: 
Colleen LaBelle, RN/Boston Medical Center
field_vote: 
Resource Type: 
Commonly Used Forms: 
Physician stage in practice: 

Medical Recordkeeping

Description: 
A description of what should be included in a buprenorphine patient's medical record.

Many portions of the medical record contain general information that is not specific to patients with substance use disorders or opioid dependence. An example of this is the history portion of the record.

The following sections of the medical record should be noted for all substance use patients:

  • Initial diagnosis and treatment plan information
  • History and physical examination
  • Comparisons with initial presentation
  • Assessment of pharmacological efficacy
  • Lab tests and results
  • Compliance with treatment plan
  • Urine and blood drug screening
  • Medications prescribed
  • Dispensing of controlled substances

Treatment Plan

The treatment plan portion of the medical record should be a natural continuation of the previous portions of the medical record. The following information should be carefully documented and shared with the patient:

  • Diagnoses and how determined
  • Treatment goals
  • Determination of medication to be used
  • How medication will be used
  • Psychosocial services required/recommended

When the practitioner reviews this information with the patient, he/she should include the patient in formulation of treatment goals. Following the patient-practitioner review, both parties should sign and date the information contained in the treatment plan. Information about buprenorphine -- such as its effects, what to expect, and what not to expect -- should be discussed with the patient, and this discussion should be documented as well. The practitioner must remember to put his or her DEA registration number on the patient's medical records, as well as the patient's prescriptions.

Physicians who are conducting office-based buprenorphine treatment should adhere to specific DEA medical recordkeeping requirements. Note that some of these requirements go beyond the standard Schedule III requirements.

Related Resources: 
Description: 
This is the full text of Title 21, Chapter 13 of the US Code, which deals with drug abuse prevention and control.
Source: 
Drug Enforcement Administration (DEA)
field_vote: 
Description: 
Manual written by the DEA to assist physicians in understanding and complying with the Federal Controlled Substances Act. Topics covered include recordkeeping requirements, rules regarding prescription, and security requirements.
Source: 
US Drug Enforcement Administration (DEA)
field_vote: 

Consent to Release Confidential Information

Description: 
Consent to Release Confidential Information

Consent to Release Confidential Information
I ___________________________________ hereby authorize and request,
Name: ______________________________________

field_vote: 

Medical Recordkeeping

Description: 
A description of what should be included in a buprenorphine patient's medical record.

Many portions of the medical record contain general information that is not specific to patients with substance use disorders or opioid dependence. An example of this is the history portion of the record.

The following sections of the medical record should be noted for all substance use patients:

field_vote: 
Commonly Used Forms: 
Description: 
The California Society of Addiction Medicine (CSAM) website provides information and materials for buprenorphine treatment providers, including screening tools and sample consent and patient agreement forms, and provides links to other helpful resources.
Source: 
California Society of Addiction Medicine (CSAM)
field_vote: 
Description: 
An example of the wording and structure necessary in a consent for release of information form.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
field_vote: 
Resource Type: 
Commonly Used Forms: 
Physician stage in practice: 
Description: 
This website from the American Academy of Family Physicians provides information about HIPAA and how physicians can implement its guidelines in their practices.
Source: 
American Academy of Family Physicians (AAFP)
field_vote: 
Physician stage in practice: 
Resource Type: 
Description: 
This clinical guidance provides information about the requirements for storing, dispensing, and maintaining records for physicians who provide office-based opioid treatment.
Source: 
Physician Clinical Support System (PCSS)
field_vote: 
Physician stage in practice: 

Pages

Subscribe to Recordkeeping