Medical Records: What Must be Included From a Prescribing Standpoint?

While prescribing controlled substances is a common part of nurse practitioner practice, it must be done with caution. NPs that don't back up the prescriptions they write with timely, accurate documentation can get themselves into a sticky situation with their employer, regulatory board, or the DEA. What needs to be included in your documentation when you prescribe controlled substances as a nurse practitioner? 

Documentation can be a big burden for NPs. It seems that healthcare providers are being increasingly called on to include more and more information in medical charts requiring precious time. Not to mention, it seems unfair that nurse practitioners must document carefully to defend their prescribing habits when it comes to patients who may be manipulative or drug-seeking. But, complete documentation is like insurance. It protects you should your actions be called into question. So, it's important that nurse practitioners take this necessary evil seriously on a day-to-day basis, particularly when it comes to prescribing controlled substances

I recently had a chance to chat with healthcare attorney Alex Fisher about medical records and prescribing. Alex mentioned a few best practices nurse practitioners should use when prescribing controlled substances to back up their decision making and protect themselves from disciplinary action. Here are a few of her recommendations:

  1. Document a complete social history including a history of drug and alcohol abuse
  2. Get a pain management contract in place and maintain this as part of the patient's medical record for individuals who are prescribed these types of medications on a long-term basis. 
  3. Consider drug testing patients who are prescribed controlled substances. Make sure your practice has a protocol in place regarding next steps when drug test results are inconsistent with the patient's prescribed medication regime. 
  4. Discuss (and document!) pain management alternatives before prescribing narcotic medications. Regulatory boards like to see that patients have explored options aside from long term pain management with prescription drugs. 
  5. Make use of state controlled substance medication prescribing databases before prescribing controlled substances. In some states this is required by law. Document that you have checked this record. 
  6. Don't prescribe without documentation. Even if you aren't charging a patient for a visit where controlled substances are prescribed, medical documentation is required. 

Check out this clip for my full conversation with Alex Fisher regarding medical record keeping and the prescribing of controlled substances. 


Did you find this video segment helpful? View more MidlevelU video content on MyMidlevelU. Get started by creating a MyMidlevelU account and clicking 'eCourses'. 

If you have a question related to prescribing controlled substances as a nurse practitioner, attorney Alex Fisher is happy to help. She can be reached at


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