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Use of the Controlled Substance Alert Within the Medical Record (3.2.2)

Use of the Controlled Substance Alert Within the Medical Record (3.2.2) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Medical Record


Policy Title: Use of the Controlled Substance Alert Within the Medical Record
Policy Number: 3.2.2
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: October 8, 2015


To establish a formal policy and provide procedures for using the controlled substance alert (CSA) w ithin
(Health Link) electronic medical records. This policy and the procedures w ithin guide the use of the alert in
our electronic health record system.


A. Pharmacist – Controlled Substance Alert Reviewer (CSAR): refers to a pharmacist authorized to perform
controlled substance alert review
B. NFS: refers to a situation w here “No Further Service” w ill be provided to an established patient by a specif ic
provider(s), service/department/clinic or all of UW Health to a patient w ho is currently receiving or previous ly
received care.
C. UW Health: includes University of Wisconsin Hospitals and Clinics (UWHC), University of Wisconsin
Medical Foundation (UWMF), the University of Wisconsin School of Medicine and Public Health (SMPH),
and health care providers associated w ith any of those organizations.


Documentation may be placed w ithin Health Link to alert health care providers of the possible need for
special attention in prescribing controlled substances. This policy outlines the specif ic steps required before
placing such an alert w ithin Health Link. A Controlled Substance Alert (CSA or Alert) is an alert; it is not a
determination that the person is a controlled substance abuser.


A. Factors to consider in placing a Controlled Substance Alert.
i. The follow ing factors may indicate the need for an Alert, but other circumstances must be
considered because individuals w ho do not need an Alert may engage in some of these behaviors.
a. There is a pattern of patient calls to clinical staff for a controlled substance prescription
due to loss/w astage or a depleted supply.
b. There is a pattern of patient requests for a specif ic controlled substance versus the
medication offered during an appointment.
c. There is a pattern of visits to Urgent Care or Emergency Room facilities seeking treatment
w ith a controlled substance.
d. Patient has not abided by a pain management agreement.
e. Patient has repeated appointments for controlled substance prescriptions or is seen on a
regular basis for the same condition requiring treatment w ith a controlled substance.
f. Other circumstances deemed suspect by a health care provider.
ii. For pharmacy staff, the follow ing additional factors may indicate the need for an Aler t:
a. History of multiple controlled substance prescriptions dispensed/w ritten by more than one
b. Forged prescription presented.
c. Fraudulent call-in prescription.
iii. Notif ication from outside sources.
a. Proceed to Section (IV.)B
iv. If the CSA is requested for an employee of UW Health or non-employee authorized to practice at
UW Health and the request is based on criminal behavior (e.g., forgery) or other information
obtained outside the scope of the provider-patient relationship, the Chief Human Resources Officer
(CHRO) or Chief Medical Officer (CMO) may be contacted for further guidance. Protected health
information generally should not be disclosed to the CHRO or CMO w ithout the patient’s
permission. If there is a question about w hether information may be disclosed, legal services
department should be consulted.
B. Requesting/investigating the addition or removal of a CSA

Policy Title: Use of the Controlled Substance Alert Within the Medical Record
Policy Number: 3.2.2

i. A CSA request may be submitted by a manager, physician, advanced practice provider, or
ii. A Pharmacist –CSAR w ill conduct an investigation that may include some or all of the follow ing:
a. Review of the patient’s medical record
b. Review of the patient’s Wisconsin Prescription Drug Monitoring Program record.
c. UW Health Community Pharmacy patient profile for documentation of forged or
fraudulent prescription history.
d. Discussions w ith other health care providers involved w ith the patient’s care
C. Controlled Substance Alert Addition or Removal Determination:
i. After the investigation, a Pharmacist – CSAR w ill recommend w hether a CSA should be
posted or removed
ii. The appropriate physicians and/or advanced practice providers w ill be informed of the Pharmacist
– CSAR recommendation. The appropriate medical staff member shall be in the follow ing priority
order, a physician/NP/PA w ho prescribed controlled substances for the patient, the patient’s
primary care provider, or the attending physician. If a provider disagrees w ith the decision, the
situation w ill be referred to the Chief Medical Officer or their designee to determine w hether a CSA
is appropriate.
iii. The Pharmacist - CSAR w ill defer to the prescriber w ho prescribed controlled substances for the
patient and the patient’s primary care provider regarding w hether to inform the patient that a
decision has been made to post the CSA, except in unusual cases (e.g., law enforcement request,
safety concerns, etc.) w here disclosure is inappropriate. When the patient is informed,
documentation in the medical record is required. The follow ing people may be contacted for
a. Pharmacist – CSAR
b. Patient Resources
c. Legal Services
d. Chief Medical Officer
iv. If the patient has been involved in fraudulent activity related to controlled substances, the
Pharmacist – CSAR may, after consultation w ith primary care provider and patient resources,
recommend that the patient receive no further service.
D. Internal Communications.
i. Health Link. When it has been decided that a CSA is appropriate, a Pharmacist – CSAR is
responsible for entering the CSA as an FYI in Health Link, including a summary of the basis for the
ii. The Pharmacist – CSAR shall retain a record of the basis for the determination of the need for the
CSA for 2 years.
iii. Pharmacist-CSAR w ill add or remove the CSA in the UW Health Community pharmacy computer
iv. For questions regarding the CSA, clinicians can review Health Link and/or contact the pharmacy to
obtain additional details of the situation as needed.
E. Future interactions w ith persons w ith a CSA:
i. Before prescribing controlled substances to a person w ith a CSA, a prescriber w ho is not familiar
w ith the basis for the CSA should review the basis for the Alert. In some cases it may be
appropriate to consult w ith prescribers or pharmacists previously involved w ith the patient or
familiar w ith addressing CSAs. It may be appropriate to refuse to prescribe controlled subs tances,
limit the amounts prescribed, or put other arrangements in place.
F. Follow -up:
i. Questions regarding the current status of a CSA should be forw arded to a Pharmacist – CSAR.


Controlled Substance Alert Report Form


Author(s): Director, Pharmacy Services
Senior Management Sponsor: SVP and General Counsel
Review ers: UWHC Legal Department; UWMF Legal Services; Medical Director for Ambulatory Operations;

Policy Title: Use of the Controlled Substance Alert Within the Medical Record
Policy Number: 3.2.2

Director, Ambulatory Nursing
Approval committees: P & T Committee, UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: August 17, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


Appendix A: Brief Analysis of Law s and Regulations Relating to Controlled Substances

Version: Revision
Next Revision Due: October 8, 2018
Formerly Know n as: Hospital Administrative policy #6.43; MF policy, Use of the Controlled Substance Alert
w ithin the Medical Record