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AHIMA Offers Clinical Documentation Tips for Opioid Abuse

A few simple tweaks to clinical documentation habits may help fuel more effective responses to the opioid abuse epidemic.

Clinical documentation improvement and opioid abuse

Source: Thinkstock

By Jennifer Bresnick

- Substance use disorders (SUDs) are becoming devastatingly common as the opioid abuse epidemic rages on, but providers may not be creating clinical documentation with a high enough quality to use in SUD research and population health management initiatives.

Insufficient clinical documentation and poor data integrity can stymy data analytics projects aimed at identifying risks, understanding patterns in SUD prevalence, and ensuring that patients suffering from opioid abuse issues receive the treatment they need to recover.

“It is vital that organizations and providers provide high quality clinical documentation, to guarantee the data which drives research and education on this topic is based on the correct information,” said the American Health Information Management Association (AHIMA).

Providers must practice and refine their ability to create documentation that meets the seven criteria for good clinical notetaking: the documentation must be legible, reliable, precise, complete, consistent, clear, and timely, AHIMA says.

To guide providers towards the ability to create useful and accurate documentation for substance abuse disorders, AHIMA has published a tip sheet that provides specific examples for how to meet each of these seven goals.

“In the tip sheet, each of the seven characteristics of high quality clinical documentation are listed in the first column,” the organization explains.

“Under the example column are scenarios of when each of these characteristics is missing within the clinical documentation. The final column provides an example of poor documentation that is frequently seen in opioid documentation. Then there is an explanation of the missing clarity followed by what a high quality documentation statement would look like.”

Providers are reminded to ensure that their notes meet the threshold for completeness, for example, with the following sample documentation:

  • Poor Quality: 42-year-old female admitted for somnolence and abnormal drug screening.
  • Missing Clarity: What is the diagnosis to support the abnormal finding?
  • High Quality: 42-year-old female admitted with drug dependence and intoxication of Oxycodone as evidenced by positive drug screen for opioids.

Optimal clinical documentation for opioid disorders or other substance abuse issues should contain key elements including the patient’s age and gender, type of interaction with the provider, mental health comorbidities, and whether the patient was intoxicated or going through withdrawal at the time of the visit.

An example of a high-quality statement that contains all necessary elements to fully describe an SUD encounter would be “25 year old female was admitted with opioid abuse, intoxication, withdrawal, and type II Bipolar disorder,” AHIMA says.

Now a national public health emergency, the opioid epidemic continues to take thousands of lives across the country despite the healthcare system’s efforts to respond to the crisis effectively.

Health IT and data analytics tools are helping providers, payers, and public health officials to better understand the epidemic and target resources to high-needs individuals, but such strategies rely on having access to complete, accurate, and timely data from the providers treating patients on the front lines.

Improving the quality of clinical documentation could be an important way to equip stakeholders with the tools they need to combat substance abuse without requiring significant time, resources, or technology investments from hospitals and physician organizations.

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