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 documentation of past history, medications, or chest auscultation; or a chart of a patient with a fractured humerus with no medication, allergies, age, past history, or physical exam beyond right arm range of motion; or an obstetric patient with a chart as described above.
While such completeness is unfortunately missing from many doctors' charts, I see nothing more special about pain management that necessitates rules different from any other medical care. The enormous uptick in addiction and even deaths from opiate overdose with improperly prescribed medications and lack of physician supervision will not be stopped by "requiring" proper basic medical documentation.
David H. Janowitz, MD
November 2015 Texas Medicine Contents
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