Documents you make (including clinical records) must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
Clinical records should include:
relevant clinical findings that support the decision to prescribe opioids
the intended outcomes of opioid therapy as agreed with the patient
the choice of drug, formulation, dose and duration of treatment
a clear account of how, when and in what circumstances the dose of drug should be adjusted (this should be given to the patient)
the circumstances under which opioid therapy should be discontinued
