Computerized progress notes for chronic pain patients receiving opioids; the Prescription Opioid Documentation System (PODS).

OBJECTIVE: We herein provide a description of a health information technology tool using computer-assisted survey instruments as a methodology for documentation during long-term opioid therapy.
DESIGN: We report our experience using the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that utilizes validated questionnaires to automate the assessment of opioid prescribing for chronic nonmalignant pain. SETTING AND PATIENTS: Chronic pain patients answered questions that were presented on a computer terminal prior to each appointment in a Department of Veterans Affairs Pain Clinic. MEASURES: Pain levels, activities of daily living, and screening for common psychological disorders were sought at each visit. Results were tabulated with some information gathered sequentially permitting evaluation of progress. Following a face-to-face interview, the clinician added additional comments to the medical record.
RESULTS: By deploying a systematic series of questions that are recalled by the computer, PODS assures a comprehensive assessment.
CONCLUSIONS: The PODS fulfills medicolegal requirements for documentation and provides a systematic means of determining outcomes. This process facilitates the determination of the appropriate intervals between clinic visits by stratifying patients into high, moderate, and low risk. Wiley Periodicals, Inc.