Section 246-919-905 - Patient evaluation and patient record-Chronic 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.Wash. Admin. Code § 246-919-905
Adopted by WSR 18-23-061, Filed 11/16/2018, effective 1/1/2019