Clinical SOP • Medication Management
Controlled Substances
Evaluate, prescribe, monitor, document, renew, and discontinue controlled medications safely while supporting legitimate patient care, reducing diversion risk, and meeting federal, state, licensing, and organizational requirements.
Purpose
Controlled medications require enhanced clinical review, documentation, monitoring, patient education, prescribing authority, and diversion prevention.
Controlled substances may be prescribed only by a provider who is appropriately licensed, registered, credentialed, and authorized for the medication, schedule, patient location, and type of clinical care being provided.
Scope
Schedule II Medications
Includes medications with accepted medical uses and a high potential for misuse or dependence. Schedule II prescriptions are not processed as routine refills.
Schedule III–V Medications
Includes controlled medications with varying levels of misuse and dependence risk. Prescribing and renewal limits remain subject to law, clinical judgment, and TNC policy.
Opioid Medication
Includes opioid analgesics and other opioid products requiring medication-specific risk assessment, monitoring, and patient education.
Stimulant Medication
Includes controlled stimulant medication used for clinically supported diagnoses and managed within the provider’s authorized scope.
Benzodiazepines and Sedatives
Includes controlled medications that may cause sedation, impairment, respiratory depression, tolerance, or withdrawal.
Other Controlled Medication
Includes testosterone products, sleep medications, weight-management medications, and other products classified as controlled substances.
Roles and Responsibilities
Prescribing Provider
Completes the clinical evaluation, confirms prescribing authority, reviews monitoring information, checks the applicable PDMP, makes the prescribing decision, and documents the treatment plan.
Medical Assistant
May collect medication history, vital signs, screening information, pharmacy details, agreement status, testing status, and patient concerns for provider review.
Clinical Support Staff
May receive and route requests, collect outside records, assist with authorized monitoring workflows, and communicate the provider’s documented instructions.
Clinical Leadership
Supports training, audit review, incident escalation, diversion concerns, policy implementation, and unresolved controlled-substance workflow concerns.
Required Prescriber Authority
Active Professional License
The provider must hold an active license that permits the clinical evaluation and prescribing activity.
DEA Registration
The provider must maintain an active DEA registration appropriate for the controlled substances prescribed and required practice location.
State Prescribing Authority
The provider must meet applicable state prescribing, supervisory, collaborative, furnishing, and controlled-substance requirements.
Location Authority
The provider must be authorized to treat and prescribe for the state where the patient is physically located.
Medication Schedule
The provider’s authority must include the specific controlled medication and schedule being considered.
TNC Credentialing and Privileges
The provider must remain approved to provide the relevant service within TNC’s credentialing and clinical structure.
Required Clinical Evaluation
Patient Identification
Verify the patient with two identifiers and confirm the correct RXNT chart, encounter, provider, and clinic location.
Diagnosis and Indication
Confirm a clinically supported diagnosis or indication that is within the provider’s scope and treatment plan.
History and Examination
Complete the history, examination, screening, and clinical assessment required for the medication and condition.
Medication Reconciliation
Review prescriptions, controlled medications, over-the-counter products, supplements, outside medications, and actual patient use.
Allergy Review
Review allergies, prior reactions, intolerances, and conflicting information.
Substance-Use History
Assess relevant alcohol, cannabis, illicit substance, prescription misuse, overdose, treatment, and recovery history.
Mental-Health Review
Assess relevant anxiety, depression, mania, psychosis, suicidal thoughts, behavioral concerns, and outside behavioral-health care.
Medical Risk Factors
Review respiratory disease, sleep apnea, pregnancy, renal or hepatic disease, cardiovascular risk, falls, cognitive impairment, and other medication-specific risks.
Prior Treatment
Review non-controlled alternatives, prior controlled medications, treatment response, side effects, dose changes, and reasons for discontinuation.
Outside Prescribers
Identify other clinicians prescribing controlled medications or treating the same condition.
PDMP Review
Review the applicable prescription monitoring program as required by law, professional standards, medication type, and TNC policy.
Monitoring Requirements
Confirm required visits, laboratory testing, vital signs, screening, toxicology testing, medication agreements, and other monitoring.
Standard Controlled-Substance Workflow
Verify the Patient and Encounter
Confirm the patient’s full name, date of birth, provider, location, appointment type, and date of service.
Confirm Prescribing Authority
Confirm the provider is licensed, registered, credentialed, and authorized for the medication, schedule, patient state, and clinical service.
Complete the Clinical Evaluation
Establish the diagnosis, indication, treatment goals, expected benefit, patient-specific risk, and available alternatives.
Reconcile Medications
Review all active medications, controlled substances, sedating medications, outside prescriptions, supplements, and actual use.
Review the PDMP
Review the applicable state monitoring program and evaluate prescribers, pharmacies, dates, quantities, overlapping medication, early fills, and other relevant findings.
Complete Risk Assessment
Assess misuse risk, overdose risk, medication interactions, substance-use history, mental-health concerns, and ability to follow the treatment plan.
Review Required Agreements and Monitoring
Confirm the controlled-substance agreement, informed consent, toxicology testing, pill counts, follow-up visits, or other required elements when applicable.
Consider Non-Controlled Alternatives
Evaluate whether non-controlled medication, therapy, behavioral intervention, specialty care, physical treatment, or another option may safely meet the treatment goal.
Select the Medication and Dose
Choose the appropriate medication, formulation, strength, dose, route, frequency, duration, quantity, and monitoring plan.
Complete the Safety Review
Review allergies, interactions, duplicate therapy, pregnancy concerns, contraindications, and overlapping sedating medications.
Confirm the Pharmacy
Verify the pharmacy name and location before transmission and review whether the patient is following any required pharmacy limitation.
Educate the Patient
Explain benefits, risks, impairment, storage, disposal, interactions, overdose concerns, treatment expectations, and refill rules.
Issue the Prescription
The authorized provider personally reviews, signs, authenticates, and transmits the prescription through the approved prescribing process.
Document the Treatment Plan
Document the clinical indication, risk-benefit decision, PDMP review, medication details, education, monitoring, and follow-up.
Schedule Follow-Up
Establish the next visit, testing, monitoring, specialist care, and circumstances requiring earlier evaluation.
Prescription Monitoring Program Review
Patient Match
Confirm the report belongs to the correct patient and review possible alternate names or demographic variations.
Medication History
Review controlled medications, quantities, dates, days supplied, and medication combinations.
Prescribers
Identify the number and type of prescribers involved in the patient’s controlled-medication care.
Pharmacies
Review pharmacy use and identify unexpected or unexplained changes.
Timing
Review early fills, overlapping supplies, recently issued prescriptions, and timing inconsistent with the reported history.
Medication Combinations
Review combinations that increase sedation, impairment, overdose, or other clinical risk.
Controlled-Substance Agreement
A controlled-substance agreement may be required based on medication type, duration of treatment, provider judgment, state requirements, and TNC policy.
One Coordinating Prescriber
The patient should understand which clinician coordinates the controlled-substance treatment plan.
Pharmacy Expectations
The patient should understand any requirement to use a designated pharmacy or notify TNC before changing pharmacies.
Medication Security
Medication must be secured from children, visitors, household members, theft, and unauthorized access.
No Sharing or Selling
The patient must not share, trade, sell, or provide medication to another person.
Monitoring Participation
The patient must complete required visits, laboratory testing, toxicology testing, pill counts, referrals, and other monitoring.
Medication Changes
The patient should not independently increase, decrease, stop, restart, combine, or replace medication.
Lost or Stolen Medication
The agreement should explain that replacement is not guaranteed and remains subject to provider review and applicable policy.
Early Requests
Early prescription requests are reviewed individually and may be denied or require additional assessment.
Outside Controlled Medication
The patient must report controlled substances received from emergency, dental, surgical, specialist, or other outside care.
Agreement Violation
Failure to follow the treatment plan may result in additional monitoring, modification, tapering, discontinuation, or referral.
Ongoing Monitoring
Clinical Benefit
Confirm that the medication supports measurable improvement in symptoms, function, safety, or another defined treatment goal.
Adverse Effects
Assess sedation, falls, constipation, mood changes, cardiovascular symptoms, sleep concerns, appetite changes, and other medication risks.
Medication Adherence
Assess whether the patient takes the medication as prescribed and whether doses are missed, changed, shared, or used differently.
PDMP Review
Repeat monitoring-program review according to applicable law, patient risk, medication type, and TNC policy.
Toxicology Testing
Complete testing when clinically indicated or required and review results in context rather than using results without clinical interpretation.
Pill Counts
Complete medication counts when required by the provider, agreement, clinical concern, or policy.
Vital Signs and Laboratory Testing
Monitor blood pressure, pulse, weight, laboratory values, or other medication-specific measures.
Outside Care
Review emergency visits, hospitalizations, specialist treatment, dental care, surgery, and outside controlled prescriptions.
Risk Changes
Reassess pregnancy, substance use, mental health, overdose risk, cognition, respiratory disease, housing security, and other changes.
Continued Need
Reassess whether the medication remains necessary and whether the benefits continue to outweigh the risks.
Prescription and Renewal Requests
Verify the Patient
Confirm full name, date of birth, callback information, medication, strength, directions, and pharmacy.
Check for Duplicate Requests
Review existing tasks, portal messages, pharmacy requests, prescriptions, and telephone encounters before creating a new task.
Review the Last Prescription
Confirm medication, strength, quantity, directions, date issued, expected supply, pharmacy, and prescription status.
Review Follow-Up and Monitoring
Confirm required visits, agreements, PDMP review, testing, vital signs, specialist care, and other monitoring.
Identify Special Circumstances
Document early requests, lost or stolen medication, travel, pharmacy shortage, hospitalization, outside prescriptions, dose differences, or adverse effects.
Route to the Prescriber
Route the complete request to the responsible provider without promising approval or a specific completion time.
Communicate the Decision
Communicate approval, denial, appointment requirements, monitoring instructions, medication changes, or referral exactly as documented.
Close Only After Resolution
Confirm the prescription was transmitted or the request was otherwise resolved before closing the workflow.
Early Refill Requests
An early request must be documented and routed for provider review. Approval is not guaranteed and should not be promised by staff.
Lost, Stolen, Damaged, or Destroyed Medication
Document the Report
Record what occurred, when it occurred, medication information, quantity believed missing, and remaining supply.
Do Not Promise Replacement
Explain that replacement requires provider review and may not be approved.
Collect Supporting Information
Obtain police-report information, pharmacy information, travel details, damaged packaging, or other documentation when requested.
Review History
Review prior lost, stolen, damaged, early, or replacement requests and applicable monitoring information.
Route for Provider Decision
The provider determines whether to deny, replace, modify, taper, monitor, refer, or otherwise address the request.
Pharmacy Shortage or Transfer Request
When the pharmacy cannot fill a prescription, verify whether the prescription remains active, partially filled, transferred, canceled, or unavailable before taking additional action.
Concerning Findings
Multiple Prescribers
Unexpected controlled prescriptions from multiple clinicians without clear care coordination.
Multiple Pharmacies
Frequent unexplained pharmacy changes or inconsistent pharmacy use.
Repeated Early Requests
Repeated reports of running out early or requesting medication before the expected date.
Repeated Lost or Stolen Medication
Multiple reports of medication loss, theft, destruction, spilling, or missing quantities.
Unexpected Toxicology Result
Results inconsistent with the prescribed treatment plan or reported substance use.
Medication Alteration
Evidence that prescriptions, containers, labels, pill quantities, or records may have been altered.
Escalating Dose Requests
Repeated requests for higher doses without a supporting clinical assessment.
Unsafe Medication Combination
Concurrent controlled or sedating medications that may increase impairment or overdose risk.
Agreement Concerns
Missed appointments, declined monitoring, unauthorized medication use, or failure to follow the treatment plan.
Behavioral Concern
Threats, coercion, prescription manipulation, suspected diversion, or another significant safety concern.
Provider Response Options
Continue Treatment
Continue when benefits remain clinically meaningful and risks remain appropriately managed.
Modify Treatment
Change the medication, dose, quantity, frequency, monitoring plan, or follow-up interval.
Increase Monitoring
Require more frequent visits, PDMP review, toxicology testing, pill counts, or care coordination.
Use a Limited Supply
Authorize a limited quantity while additional assessment, records, monitoring, or follow-up is completed.
Decline the Request
Deny a prescription or replacement when it is not clinically appropriate or required information is unavailable.
Taper or Discontinue
Establish an appropriate provider-directed plan when continued treatment is no longer safe or beneficial.
Refer to a Specialist
Refer for pain management, psychiatry, addiction treatment, behavioral health, sleep care, or another specialty when appropriate.
Coordinate With Outside Care
Contact outside prescribers, pharmacies, hospitals, or specialists to clarify overlapping treatment.
Tapering or Discontinuation
Tapering or discontinuation is a clinical decision made by the prescribing provider based on medication type, duration of use, patient risk, treatment response, withdrawal risk, and the reason for the change.
Patient Education
Medication Purpose
Explain the condition being treated and the expected treatment goal.
Directions
Review the dose, route, frequency, timing, duration, and maximum permitted use.
Impairment
Explain medication-specific driving, operating-equipment, work, fall, and decision-making risks.
Medication Interactions
Review important interactions with alcohol, sedatives, opioids, stimulants, sleep products, cannabis, and other medications.
Overdose and Emergency Signs
Explain medication-specific emergency symptoms and when to call 911.
Secure Storage
Instruct the patient to store medication securely and away from children and unauthorized individuals.
No Sharing
Explain that controlled medication must never be shared, sold, traded, or provided to another person.
Safe Disposal
Explain approved medication take-back or product-specific disposal options.
Renewal Expectations
Explain appointment, testing, monitoring, pharmacy, timing, and controlled-medication request requirements.
Teach-Back
Ask the patient to explain how they will use, store, and monitor the medication.
Suspected Diversion or Fraud
Report suspected prescription alteration, identity misuse, diversion, theft, unauthorized access, credential misuse, forged communication, or fraudulent prescribing activity to clinical and organizational leadership immediately.
Medication Error or Unauthorized Prescription
Protect the Patient
Determine whether the patient received or used the medication and assess whether urgent clinical action is required.
Notify the Provider and Leadership
Escalate the event immediately to the prescribing provider and appropriate organizational leadership.
Contact the Pharmacy When Directed
Clarify whether the prescription was received, filled, transferred, canceled, or dispensed.
Correct the Active Treatment Plan
The provider determines whether the prescription must be canceled, replaced, modified, or clinically addressed.
Document the Clinical Event
Document patient assessment, provider instructions, pharmacy communication, treatment actions, and follow-up.
Complete Internal Reporting
Complete the required safety, compliance, privacy, or security reporting process separately from the medical record.
Do and Do Not
Always Do
- Verify the correct patient and encounter.
- Confirm the provider’s prescribing authority.
- Complete an appropriate clinical evaluation.
- Reconcile all medications and controlled substances.
- Review the applicable PDMP when required.
- Assess misuse, interaction, and overdose risk.
- Review required agreements and monitoring.
- Confirm the correct medication and pharmacy.
- Educate the patient about safety and storage.
- Document the risk-benefit decision.
- Track requests until final resolution.
- Report suspected diversion or credential misuse.
Never Do
- Promise a controlled prescription will be approved.
- Process Schedule II medication as a refill.
- Use another person’s prescribing credentials.
- Share provider authentication information.
- Issue a prescription without a legitimate clinical purpose.
- Ignore PDMP or medication-history concerns.
- Change the dose or quantity without provider authorization.
- Promise replacement of lost or stolen medication.
- Create duplicate prescriptions without checking status.
- Tell a patient to borrow or share medication.
- Alter documentation to hide an error.
- Ignore suspected diversion, fraud, or unauthorized access.
RXNT Documentation
Detailed screenshots belong in the RXNT Center. Use the following documentation standard for controlled-substance workflows.
Patient and Encounter
Confirm the patient, date of birth, provider, location, encounter, and date of service.
Clinical Indication
Document the diagnosis, symptoms, functional concerns, examination, and treatment goals.
Medication Reconciliation
Update active controlled substances, other medications, outside prescriptions, and actual patient use.
PDMP Review
Document completion and relevant clinical findings according to applicable requirements.
Risk Assessment
Document substance-use history, mental-health concerns, interactions, overdose risk, and relevant medical conditions.
Agreement and Monitoring
Document agreement status, toxicology testing, pill counts, laboratory testing, vital signs, and other monitoring.
Prescription Details
Confirm medication, formulation, strength, dose, route, frequency, duration, quantity, and pharmacy.
Clinical Decision
Document the expected benefit, identified risks, alternatives considered, and reason for continuing or changing treatment.
Patient Education
Document safety, impairment, interactions, storage, disposal, monitoring, and request expectations.
Follow-Up Plan
Document required appointments, monitoring, testing, referrals, and conditions requiring earlier evaluation.
Prescription Status
Confirm whether the prescription was transmitted, canceled, replaced, transferred, denied, or otherwise resolved.
Patient Communication
Document the outcome, communication method, instructions, and patient understanding when applicable.
Employee Competency
Employees should demonstrate each controlled-substance responsibility assigned to their role.