Texas Medicine Inbox: November 2015 - 05/13/2016
Inbox — November 2015
I am an obstetrician-gynecologist in Houston. I read with interest the article on Texas Medical Board (TMB) rules for pain management treatment in the September issue. (See "Regs and Pains," September 2015 Texas Medicine, pages 51-55) The rules include documentation of a history and physical, test results, consultations, treatment plan, and informed consent, including risks and benefits, treatment given, medication, instructions and agreements, and follow-up.
Granted, in chart reviews for hospital peer review committees, I often come across charts with a history and physical without age, sex, last menstrual period, past history, or any physical exam beyond a cervix check. Obviously, those charts show grossly inadequate documentation. Similarly, the criteria listed in these new TMB rules list only basic, standard documentation.
The information listed in the board rules should be present on all medical records. Imagine a cardiac patient's chart without docume...