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Patient Acknowledgment of Risk of Controlled Substance & Opioid Use


Consistent Messaging
Beginning July 19, 2018, ALL CHI Health entities in Nebraska and Iowa will utilize a universal form across the division.

The“Patient Acknowledgment of Risk of Controlled Substance and Opioid Use” will be used in both the inpatient and outpatient settings.

Ambulatory Clinic Settings
The “Patient Acknowledgment of Risk of Controlled Substance and Opioid Use” will be completed:

  • Prior to the FIRST prescription of a Schedule II medication for pain
  • Prior to the THIRD prescription of a  Schedule II medication for pain
  • Existing prescriptions - prior the NEXT SCHEDULED prescription RENEWAL
  • ANNUALLY for all patients on long-term use of Schedule II medications for pain

Hospital Settings
The “Patient Acknowledgment of Risk of Controlled Substance and Opioid Use” will be completed:

  • At discharge for all patients prescribed Schedule II medications for pain

Ambulatory Documentation

  • Signed and witnessed acknowledgment will be scanned into the electronic medical record
  • - Risk of addiction and overdose
    - Reasons why a prescription is necessary
       ° Medical necessity if > 7-day supply is needed
  • Provider responsible to document components of law have been met:
    - Alternatives to treat pain that may be available
    - Iowa only: PMP reviewed
    - Nebraska: Best practice to review PDMP and document