Name of the Procedure:

HCPCS G9697 - Documentation of Patient Reason(s) for Not Prescribing a Long-Acting Inhaled Bronchodilator

Summary

This procedure involves documenting the specific reasons why a long-acting inhaled bronchodilator was not prescribed to a patient. This typically includes patient-specific considerations such as preferences, clinical contraindications, or situations where the inhaler is not suitable.

Purpose

The purpose of this documentation is to provide a clear rationale for not prescribing a long-acting inhaled bronchodilator, ensuring accurate medical records and aiding in the continuity of care. It addresses:

• Ensuring patient safety
• Honoring patient preferences
• Justifying clinical decisions

Indications

This procedure is indicated when:

• A patient is unable or unwilling to use a long-acting inhaled bronchodilator due to specific reasons.
• Clinical contraindications exist that make the use of such medications unsafe for the patient.
• Alternative treatment options are more suitable for the patient's condition.

Patient criteria include:

• Documented allergies or adverse reactions to the bronchodilator
• Patient refusal or non-compliance concerns
• Comorbid conditions that contraindicate the use of bronchodilators

Preparation

Patients should:

• Discuss their medical history and medication preferences with their healthcare provider.
• Undergo necessary assessments to determine the appropriateness of a long-acting inhaled bronchodilator.

Procedure Description

1. Initial Assessment: Conduct a thorough patient history and clinical assessment.
2. Discussion: Engage in a detailed discussion with the patient regarding the benefits and risks of using a long-acting inhaled bronchodilator.
3. Documentation: Clearly document the patient's reason(s) for not prescribing the medication, including any contraindications, preferences, or other relevant factors.
4. Alternative Planning: Explore and document alternative treatment options discussed with the patient.

Tools/Equipment:

• Electronic Health Record (EHR) system for documentation
• Standard clinical assessment tools

Duration

The documentation process typically takes 10-15 minutes, depending on the complexity of the case.

Setting

The procedure is usually performed in:

• Outpatient clinic
• Physician's office
• Hospital setting during a patient visit

Personnel

• Primary Care Physician
• Pulmonologist
• Nurse Practitioner or Physician Assistant
• Medical Assistants

Risks and Complications

Minimal risks are associated with the documentation procedure itself. The primary risks involve:

• Incomplete or erroneous documentation leading to suboptimal patient care
• Legal or compliance issues if documentation is not thorough

Benefits

The primary benefit is ensuring that patient care decisions are well-documented and justified, leading to improved patient safety and continuity of care. Benefits are often immediate as they aid in clinical decision-making and future care planning.

Recovery

No recovery period is needed as this is a documentation procedure.

Alternatives

• Directly prescribing a different class of medication
• Referring to a specialist for further evaluation and alternative treatment options

Pros and Cons:

• Pros: Better alignment with patient preferences and safety.
• Cons: May require more time to find an appropriate alternative treatment.

Patient Experience

During the discussion and documentation:

• The patient might experience relief knowing their preferences are considered.
• Patients should feel comfortable discussing any concerns and know that these are taken seriously.

Pain management and comfort measures are not applicable as this is a non-invasive documentation procedure.