246-919-900  <<  246-919-905 >>   246-919-910

WAC 246-919-905

Patient evaluation and patient recordChronic pain.

When the patient enters the chronic pain phase, the patient shall be reevaluated as if presenting with a new disease. The physician shall include in the patient's record:
(1) An appropriate history including:
(a) The nature and intensity of the pain;
(b) The effect of pain on physical and psychosocial function;
(c) Current and relevant past treatments for pain, including opioids and other medications and their efficacy; and
(d) Review of comorbidities with particular attention to psychiatric and substance use.
(2) Appropriate physical examination.
(3) Ancillary information and tools to include:
(a) Review of the PMP to identify any medications received by the patient in accordance with the provisions of WAC 246-919-985;
(b) Any pertinent diagnostic, therapeutic, and laboratory results;
(c) Pertinent consultations; and
(d) Use of a risk assessment tool that is a professionally developed, clinically recommended questionnaire appropriate for characterizing a patient's level of risk for opioid or other substance use disorders to assign the patient to a high-, moderate-, or low-risk category.
(4) Assessment. The physician must document medical decision making to include:
(a) Pain related diagnosis, including documentation of the presence of one or more recognized indications for the use of pain medication;
(b) Consideration of the risks and benefits of chronic opioid treatment for the patient;
(c) The observed or reported effect on function or pain control forming the basis to continue prescribing opioids; and
(d) Pertinent concerns discovered in the PMP.
(5) Treatment plan as provided in WAC 246-919-910.
[Statutory Authority: RCW 18.71.017, 18.71.800, 18.71A.800 and 2017 c 297. WSR 18-23-061, § 246-919-905, filed 11/16/18, effective 1/1/19.]
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