In light of HHS declaring the U.S. opioid overdose crisis a public health emergency Oct. 26, the American Health Information Management Association released a set of seven characteristics providers should aim for when documenting opioid addiction in patient charts.
"If a provider learns how to document using these characteristics to guide their documentation habits, they will provide trustworthy documentation," the recommendation reads.
Here are the seven characteristics of high-quality clinical documentation providers should review when noting opioid abuse or dependency in patients, according to AHIMA.
1. Clear
2. Consistent
3. Complete
4. Reliable
5. Precise
6. Legible
7. Timely
To access the AHIMA guidelines, click here.