Requirements for documenting buprenorphine therapy vary from state to state. You must obtain and review appropriate licensing regulations to assure that you are complying with all the requirements in your region.
Documentation requirements may include:
The induction order set and plan of care for starting and monitoring buprenorphine.
Evidence of the buprenorphine eligibility criteria. This may include lab results, physician review and sign-off of lab results, and other clinical documents. Evidence of eligibility will need to include all the elements required for the appropriate Current Procedural Terminology code.
Patient informed consent . This should include information about risks and benefits of the medication, alternative treatment methods, patient rights and responsibilities, program expectations, orientation material, fee agreements, and a therapeutic agreement.
Throughout the screening process, stress key points of the informed consent form and program expectations.
Documentation for patients who are pregnant and surgical patients
Organizations providing buprenorphine treatment to patients who are pregnant may need to complete additional documentation. As standard of best practice (and in Joint Commission accredited programs), buprenorphine prescribing physicians are required to document evidence that pregnant patients have received:
A referral to substance use disorder treatment
Education on the benefits of prenatal care
Notification of their right to refuse the referral to treatment
