practice of Medicine


Orthopedic Surgery Toolkit

Medication safety

Controlled drugs and patient management

In a physician‘s practice, there may occasionally be an issue concerning a patient and controlled drug usage. Because liability is often associated with these patients, a system of control and management should be implemented to address these liability areas. This may be accomplished by restricting access to prescription pads and syringes.

When a patient with a potential drug abuse problem has been identified, the physician should effectively monitor the patient by implement-ing the following risk management techniques:

  • Consider voluntary observations from family members regarding behavioral changes.
  • Assess periodically
    • Treatment goals
    • Cause of pain (condition vs. addiction)
    • Necessity of referral
    • Efficacy of other treatment(s)
  • Require office visits for refills.
  • Review the record prior to renewing a controlled drug.

The physician should also adhere to the following guidelines when caring for a patient on a controlled drug:

  • Annotate the patient’s history regarding the condition for which a drug is prescribed.
  • Comment on the effect of conservative, less-addictive treatment(s).
  • Document the patient’s informed consent to a treatment plan involving addictive drugs.
  • Note quantity of drugs prescribed, including total cumulative and average daily doses.

Lastly, a physician should report abusive patients by doing the follow-ing:

  • Call the police.
  • Notify state drug and narcotics agencies.
  • Inform the Composite State Board of Medical Examiners if the patient is obtaining controlled substances from other healthcare providers.

This three-pronged approach of regular monitoring, documenting and reporting will help eliminate many of the problems associated with controlled drugs.

Precautions when prescribing refills

The nurse calling in a prescription refill without physician approval is viewed as practicing medicine without a license. The public has become more aware of medication errors because ongoing media coverage on. Every physician should have processes in place to ensure safe practice when it comes to medication prescription refills. The chart should always be pulled prior to calling in a refill, and the phone calls along with the refill information should be documented in the chart. Each office should require the nurse to obtain a written or verbal order from the physician prior to each refill. Each protocol should include the following:

  • Which staff member is authorized to call in refills (should be the physician, physician extender per protocol, or a licensed nurse). If it is the nurse, include a list of medications that the nurse is allowed to call in for a refill
  • The number of times the prescription can be refilled before the patient must be seen by the physician
  • Documentation of the order as “Per Protocol Dr. Doe/nurse’s name and professional designation, i.e. RN or LPN.” The chart is then given to the physician for review and signature of the order

Allergies should be noted in a prominent way on the front of the chart and on the medication flow sheet. It is recommended that a medication flow sheet, with all medications listed, be used to prevent having to flip through progress notes to determine what medications the patient is taking. Flow sheets should be updated at each patient visit.


The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.