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am an obstetrician- gynecologist in Hous- ton. I read with in- terest the article on
Texas Medical Board (TMB) rules for pain management treatment in the September issue. (See “Regs and Pains,” September 2015 Texas Medicine, pages 51–55, or visit www.texmed
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.org/RegsandPains.) The rules include documen- tation of a history and physical, test results, consultations, treatment plan, and informed con- sent, including risks and benefits, treatment giv- en, medication, instruc- tions and agreements, and follow-up. Granted, in chart re-
views for hospital peer review committees, I of- ten come across charts that document a history and physical exam with- out age, sex, last men- strual period, past histo- ry, or any physical exam
beyond a cervix check. Obviously, those charts show grossly inadequate documentation. Simi- larly, the criteria listed in these new TMB rules list only basic, standard documentation. The information
listed in the board rules should be present on all medical records. Imag- ine a cardiac patient’s chart without docu- mentation of past his- tory, medications, or chest auscultation; or a chart of a patient with a fractured humerus with no medication, al- lergies, age, past history, or physical exam be- yond right arm range of motion; or an obstetric patient with a chart as described above. While such com- pleteness is unfortu- nately missing from many doctors’ charts, I see nothing more spe- cial about pain manage-
ment that necessitates rules different from any other medical care. The enormous uptick in ad- diction and even deaths from opiate overdose with improperly pre- scribed medications and lack of physician supervision will not be stopped by “requiring” proper basic medical documentation.
DAVID H. JANOWITZ,MD HOUSTON
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To submit a letter, email it to Texas Medicine Editor Crystal Zuzek,
crystal.zuzek@texmed.org. Please limit letters to 250 words.
6 TEXAS MEDICINE November 2015
@texmed
texmed
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