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Best Practices in Documentation for Rehab Providers
Documentation is a critical component of therapy services. Your documentation is used to communicate with other healthcare professionals, evaluate the effectiveness of treatment, and substantiate billing by justifying the care provided. Individuals who review your documentation in the medical record will never see the therapy sessions, so you have to “tell the story” by including the necessary components to justify services for reimbursement. This course covers general guidelines for documentation, components to improve documentation, and special considerations. Practical examples are provided to help you incorporate best practices into your documentation.
Identify five required components of therapy goals.
Determine at least three ways to improve documentation through the use of evidence-based practice and demonstration of skilled need and medical necessity.
Recall at least four documentation requirements across all settings.
Controlled Substances: Chronic Pain Management
Chronic pain is a common condition for which healthcare providers often prescribe controlled substances, such as opioids. Prescription opioids can alleviate pain in certain patients, but the risk of misuse, abuse, and overdose means providers need to evaluate the risks and benefits for each patient. This course will educate healthcare providers on the role of prescription opioids along with other therapies for chronic pain, using recommendations from current national guidelines.
The goal of this course is to educate healthcare providers on methods for the safe and responsible use of controlled substances for the management of chronic pain.
Indicate treatment options for patients with chronic pain.
Identify safe strategies to initiate or change opioid analgesics.
Name patient factors and characteristics that can make prescribing opioids unsafe.
Culture and Pain Management: Cultural Competence
Health inequities in pain management are prevalent across different healthcare settings. The cultural, ethnic, and social differences influence patients’ and providers’ perceptions and responses to pain. Several studies report higher incidences of pain, disability, and suffering in women and people of color compared to non-Hispanic White people. This course covers influential sociocultural factors grouped into the patient, the provider, and systemic factors. This course helps healthcare professionals become familiar with cultural differences associated with pain perceptions and management. Pain variables such as culture, religion or ethnicity are not part of standardized pain scales. Healthcare workers need to provide culturally competent care to their patients by asking about specific practices, beliefs, and values regarding pain that impacts the patient’s quality of life.
The goal of this course is to provide nurses, physicians, and social workers with an overview of cultural sensitivity in the management of pain.
Identify cultural factors influencing the patient’s perception and expression of pain.
Recall strategies for reducing barriers in pain assessment and promoting management decisions to respond to a patient’s pain in a culturally sensitive manner.
Opioid Prescribing, Chronic Pain, and Opioid Use Disorder
The emphasis on pain management to improve quality of life and function has contributed to a significant increase in opioid prescriptions. As such, there has been a concurrent increase in risk of misuse and abuse. While opioids are highly effective for pain relief, closer attention to the risk versus benefit analysis has led to guidelines that prefer nonpharmacologic and nonopioid pharmacologic therapy over opioids, especially for chronic pain. Clinicians must carefully monitor the patient and be alert for signs that risks outweigh benefits of opioids. This course will address issues related to opioid prescribing, chronic pain, and opioid use disorder.
Discuss considerations and guidelines for prescribing controlled substances.
Describe patient evaluation and education for a safe and effective pain treatment plan.
Opioid Use During Pregnancy
Americans are using opioids at an alarming rate, whether through prescriptions or illegal means. Parallel to this problem is the use of opioids during pregnancy.
The goal for this course is to present RNs, PAs, physicians, and entry-level drug and alcohol counselors in inpatient or outpatient settings with best practices for identifying and managing pregnant women who are using opioids.
Recognize the risks and complications related to opioid use disorder during pregnancy.
Identify evidence-based treatment recommendations for opioid use disorder during pregnancy.
Managing Pain Amid the Opioid Crisis
Pain management in the emergency department relies heavily on the use of opioid analgesics, which generates risk for patients to develop long term opioid use or an opioid use disorder. Multimodal analgesia can improve the patient experience and reduce the risks of opioid use if emergency providers approach pain with a more critical mindset.This activity is designed to help emergency providers improve management of pain while decreasing patient exposure to opioids. It is also designed to help providers navigate how to manage patients with opioid use disorder.
Identify different types of pain (acute pain, chronic pain, chronic cancer pain, and social pain) and the neurobiological origins of this pain.
Describe the risks associated with opioid analgesia.
Demonstrate knowledge of multimodal analgesia regimens to manage pain in the emergency department.
Describe the characteristics of opioid use disorder and the effectiveness of medication assisted therapy.
Assessing and Treating Opioid Use Disorder
Overview of Medications for Opioid Use Disorder
The current opioid use epidemic has had devastating consequences for those impacted by it. Medication for opioid use disorder (MOUD) is an effective, yet underused, approach to the treatment of opioid use disorder. By taking this course, you will have information that you can share with your clients and their family members about what MOUD is, its risks and benefits, and the types of medications used in MOUD. The goal of this course is to provide addictions, behavioral health counseling, marriage and family therapy, nursing, psychology, and social work professionals in health and human services settings with an overview of what MOUD is, how it can help individuals with opioid use disorder (OUD), and the medications used by providers that treat OUD.
Describe how opioids affect the brain and can become habit-forming.
Discuss the role of medications to treat opioid use disorder.
List the medications typically prescribed to treat opioid use disorder and the side effects and risks associated.
Opioids and Chronic Pain Management
The increased emphasis on pain management to improve functionality and quality of life has contributed to significantly more opioid prescriptions. Their availability led to widespread misuse across the nation. This course will address regulation and misuse of opioids and evidence-based management of chronic pain.
Discuss chronic pain and opioid use in the U.S.
Review the regulatory influences and evidence-based guidelines associated with prescribing controlled substances for pain management.
Describe evaluation and monitoring of the patient with pain.
Identify pharmacologic and non-pharmacologic pain management strategies.
Drug Diversion, SUD, and Pain Management
Safely managing pain for the people in your care requires you to be knowledgeable about pain management recommendations. It is important to understand the risk factors for misuse and substance use disorder (SUD) as well as the signs that someone has a SUD and how to treat it. Unfortunately, SUD is one of the drivers of drug diversion. Therefore, it is also critical that you understand drug diversion tactics and behaviors so you can help prevent it. The goal of this course is to educate healthcare providers in all settings on pain management and preventing substance use disorder and diversion.
Discuss drug diversion and related drug diversion behaviors and activities.
Identify various classifications of medications that are diverted or misused.
Describe screening and assessment tools helpful in identifying substance use disorders.
Recognize nonpharmacological and pharmacological treatments of substance use disorders.
Explain options for pain management.