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Computerized progress notes for chronic pain patients receiving opioids; the Prescription Opioid Documentation System
Barth L Wilsey1, Scott M Fishman, Carlos Casamalhuapa
1VA Northern California Health Care System, Davis, California, USA. blwilsey@ucdavis.edu
Objective:
We herein provide a description of a health information technology tool using computer-assisted survey instruments as a methodology for documentation during long-term opioid therapy.
Design:
We report our experience using the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that utilizes validated questionnaires to automate the assessment of opioid prescribing for chronic nonmalignant pain.
Setting And Patients:
Chronic pain patients answered questions that were presented on a computer terminal prior to each appointment in a Department of Veterans Affairs Pain Clinic.
Measures:
Pain levels, activities of daily living, and screening for common psychological disorders were sought at each visit. Results were tabulated with some information gathered sequentially permitting evaluation of progress. Following a face-to-face interview, the clinician added additional comments to the medical record.
Results:
By deploying a systematic series of questions that are recalled by the computer, PODS assures a comprehensive assessment.
Conclusions:
The PODS fulfills medicolegal requirements for documentation and provides a systematic means of determining outcomes. This process facilitates the determination of the appropriate intervals between clinic visits by stratifying patients into high, moderate, and low risk.
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