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/clinical/references/opiate/providers/med-agreement/resources/COE_Controlled_Med_Treatment.pdf

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Clinical Hub,References,Opiate Management Initiative,Providers,Controlled Substances Medication Agreement,Resources

Controlled Medication Treatment Agreement – Initiation or Annual Review

Controlled Medication Treatment Agreement – Initiation or Annual Review - Clinical Hub, References, Opiate Management Initiative, Providers, Controlled Substances Medication Agreement, Resources


Page 1 — Controlled Medication Treatment Agreement ©2/5/18 UW Health Information Services – HLEOS

Controlled Medication Treatment Agreement – Initiation or Annual Review

This document outlines the steps for initiating or renewing a Controlled Medication Treatment Agreement.
MA/LPN – Rooming

Important MA/LPN - 4 forms need completion (PHQ, BPI/PEG-3, Pick-up Authorization, Med
Agreement).
1. Enter Chronic Pain as chief complaint.
2. Use .dov in progress note.
3. Provide a copy of the forms to the patient for the patient to complete while waiting for the provider.
Explain the Medication Agreement should be reviewed, but will be signed with the provider.
4. Verify that Chronic Pain is documented in the Problem List. If not, it should be added.

Note It is very important to discuss the best workflow with your own provider.
Provider – Visit with Patient
• Review MA/LPN progress note.
• Review Medication List.
• Review PHQ and BPI/PEG-3 forms with patient.
• Review PDMP website. The provider or their delegate can review the website prior to the visit as well.
Chart date of review in Chronic Pain Activity/Opiate Mgmt Form.
• Enter date Med Agreement signed in Chronic Pain Activity/Opiate Mgmt Form.
• Document in the progress note using .chronicpainnotebrief.

Note Only complete the DIRE Assessment when initially starting a new opioid. Also, it is optional to
complete FAQ 5.
• Review Controlled Medication Treatment Agreement and sign it with patient.
• Review Controlled Medication Prescription Pick-up Authorization Form.
• Verify/Add Chronic Pain is documented in the Problem List. Open the details and create an overview note
using the SmartPhrase .chronicpainoverviewnote.
• Order drug screen if needed using Smartset #5404, and give Urine Drug Screen Questionnaire to patient.
• Document in the progress note using .chronicpainnotebrief.

Note It is optional to put HFFY #7716 in patient instructions.
• Give the completed forms to MA/LPN for input into HealthLink/Chronic Pain Activity.
MA/LPN – After Provider Sees Patient
1. Complete FYI for Controlled Medication Agreement using .fyimedagree. Deactivate old FYI med
agreement.

Note It is optional to enter .fyimedagree in the progress note.
2. Give the signed copies of the Controlled Medication Treatment Agreement and Controlled Medication
Prescription Pick-Up Authorization forms to reception.
3. Review the chronic pain overview note (.chronicpainoverviewnote) for completion. Fill in missing info if
available (dates, names, etc.).
4. Review/add the date Med Agreement signed in Chronic Pain Activity/Opiate Mgmt Form.
5. Open the Chronic Pain Activity and input BPI/PEG-3 and PHQ 2/9 answers.
6. If given to patient, enter urine questionnaire answers into progress note using
.urinedrugscreenquestionnaire.