Computerized progress notes for chronic pain patients receiving opioids; the Prescription Opioid Documentation System (PODS).

OBJECTIVE

We herein provide a description of a health information technology tool using computer-assisted survey instruments as a methodology for documentation during long-term opioid therapy.

DESIGN

We report our experience using the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that utilizes validated questionnaires to automate the assessment of opioid prescribing for chronic nonmalignant pain.

SETTING AND PATIENTS

Chronic pain patients answered questions that were presented on a computer terminal prior to each appointment in a Department of Veterans Affairs Pain Clinic.

MEASURES

Pain levels, activities of daily living, and screening for common psychological disorders were sought at each visit. Results were tabulated with some information gathered sequentially permitting evaluation of progress. Following a face-to-face interview, the clinician added additional comments to the medical record.

RESULTS

By deploying a systematic series of questions that are recalled by the computer, PODS assures a comprehensive assessment.

CONCLUSIONS

The PODS fulfills medicolegal requirements for documentation and provides a systematic means of determining outcomes. This process facilitates the determination of the appropriate intervals between clinic visits by stratifying patients into high, moderate, and low risk.