Controlled Substances: What to Include in Your Medical Records

Being General Counsel to several state pain societies, it often comes up about what should be reflected in your medical records concerning controlled substances. The obvious parts include the name of the substance you are prescribing, the dosage, the frequency and how it is taken. It’s astounding when reviewing a medical record that doesn’t include the prescription information written into the body of the physician’s chart. It’s surely not enough to simply state [what] the prescription is in my EMR system. A detailed written direction must be given. Should it be taken before, during or after meals? What are the side effects that accompany the prescription? If the prescription doesn’t allow any form of driving, your chart should state it. These guidelines are strictly for your protection! Also state the tolerance level of the medication, and the risk of addiction. The patient must be warned about all the risk factors of the medication if taken as prescribed. You should have all these warnings and any relevant advice given to your patient memorialized in your medical records.

Larry Kobak, Esq.
Senior Counsel
Frier Levitt
ATTORNEYS AT LAW
(516) 755-7553 direct
(973) 618-1660 office
lkobak@frierlevitt.com