Records from NeuroSpine FAIL to show the pain medications that they are prescribing to a patient in the “Medication” section. They only show up at the end of the notes when they again PRESCRIBE them and occasionally in the discussions when they are making comments about the patient’s use or their desire to take them off such medications.

Despite documentation of this in the patient’s chart, records FAIL to show the “comprehensive pain management laboratory evaluation including neuro-hormonal, metabolic, and endocrine assessments for baseline screening” and the FAILURE to be “screened successively on 3-6 month intervals as necessary for prevention of adverse effects.

Additionally they state: “Furthermore, urine toxicology alone is often not adequate to document baseline amounts of substance within the blood stream and therefore a blood toxicology will be performed either today or in the near future for corroboration and documentation of baseline blood drug content.” How about NEVER being done!

More NeuroSpine documentation FAILURES

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