Every prescription, every treatment, every surgery, everything a provider does for a patient should have a documentation of medical necessity. This includes a prescription. If they are writing for controlled substances, then a lot of pharmacies will not fill them without a diagnosis.
I am on the mailing list for the Medical Board in my state. Weekly, I get emails showing what actions the Medical Board is taking against doctors. I randomly read through the documents to see where the Medical Board is finding fault, and to make sure we are not committing any of those same errors. A very big problem relates to documentation. The doctor may have talked about it with the patient, but if it's not documented, it never happened. If a doctor prescribes, for example, xanax, but there is no documentation or diagnosis of anxiety, they have an accusation filed against them for not following standard of care, not having adequate documentation, prescribing controlled substances without documented medical necessity, etc.
Some electronic medical records make this easy for you. The ones that I like that I have seen will have each diagnosis, and then the plan for that diagnosis. For instance:
1. Major Depression, Recurrent, Moderate (
F33.1)
- Prozac, 40 mg, 1 po qd, #30 for 30 days.
- Continue psychotherapy twice monthly with psychologist.
- Return in 30 days.
2. Anxiety Disorder (
F41.1)
- Xanax, 0.5mg, 1 po q8h prn anxiety, #90 for 30 days.
- Practice daily meditation (see handout given to patient).
- Return in 30 days.
Contrast that to:
Assessment: Major Depression F33.1
Plan: Prozac 40 mg 1 po qd, #30 for 30 days; Xanax 0.5 mg, 1 po q8h prn anxiety, #90 for 90 days; Adderall 20 mg, 1 po bid #60, Nuedexta 20/10mg, 1 po qd #30, return in 30 days.
Xanax? No one said anything about anxiety.
Adderall? No one said anything about attention deficit issues.
Nuedexta? Where does it say the patient has pseudobulbar affect??