Medication Adherence

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AHIMA Opioid Addiction-Documentation Tip Sheet

November 13, 2017

Opioid addiction has been declared a public health emergency in the United States. It is vital that organizations and providers provide high quality clinical documentation, to guarantee the data which drives research and education on this topic is based on the correct information. There are seven characteristics of high quality clinical documentation. If a provider learns how to document using these characteristics to guide their documentation habits, they will provide trustworthy documentation.

This tip sheet has been developed by the American Health Information Management Association to guide providers in learning the documentation elements that are needed when documenting opioid use, abuse, or dependency. In the tip sheet, each of the seven characteristics of high quality clinical documentation are listed in the first column. Under the example column are scenarios of when each of these characteristics is missing within the clinical documentation. The final column provides an example of poor documentation that is frequently seen in opioid documentation. Then there is an explanation of the missing clarity followed by what a high quality documentation statement would look like.