Document Type



Doctor of Nursing Practice



Date of Defense


Graduate Advisor

Dr. Nancy Magnuson


Dr. Nancy Magnuson

Dr. Wilma J. Calvert

Dr. Melissa Kalaher


The Centers for Disease Control and Prevention (CDC) directives issued in 2016 gave guidelines for safely prescribing opiates; however, primary source discussions about methods used for documenting opioid and controlled substance monitoring within an electronic medical record (EMR) are limited (Hussain, Nelson, Polston & Zheng, 2019). This leaves individual providers to determine the appropriate way to document. Inconsistent documentation may not protect providers or organizations from regulatory, civil or criminal liability. As stated by Raveesh, Nayak & Kumbar (2016), “The best way to handle medico-legal issues is by preventing them”. Even with the advent and widespread use of EMRs, documentation is still often limited to basics: diagnosis, medication, dosage, procedures, referrals, and follow up (Schneider, 2014). The purpose of this project was to implement a practice improvement change which included creation of a standardized template and a central location for documentation of controlled substance monitoring. This allowed providers to document, see the dates and results for urine drug screens (UDS) or pill counts, review any concurrent schedule II or III medications, and log prescription drug monitoring database (PDMD) checks. Data indicated an improvement in documentation frequency for UDS and PDMD checks at both 30 and 60 days; however, this increase was only statistically significant for UDS at 30 days with p = 0.004. The increase was not found to be statistically significant for either UDS or PDMD checks at 60 days.