http://c-hit.org/2018/03/20/med-boar…haven-doctors/

And they are wondering What is meant when the article states that the "board reprimanded and fined a West Haven doctor $ 1,000 for failing to address a patient’s weight loss and substance abuse in 2016." They are wondering what exactly he “failed to address” or document in his notes that led to this. In particular, "his failure to address substance abuse in 2016”.

How exactly do you address that in your providers’ documentation? For patients with known active history of IV drug/heroin abuse, aside from documenting that the provider encouraged the patient to go to rehab, is there anything else that needs to be done to prevent being hit with a similar fine?

thanks!