Saturday Afternoon: An Abrasion, an Oxycodone Request, and a Phone-In for a Spouse
Dr. Boone, who holds Kentucky therapeutic privileges and a DEA registration, is covering a Saturday shift for a colleague. At 4:40 p.m. he sees a 34-year-old landscaper with a 6 mm corneal abrasion from a tree branch; he debrides loose epithelium, places a bandage contact lens, and prescribes a topical fluoroquinolone and cyclopentolate. The patient rates the pain 9/10, says 'hydrocodone never works for me,' and asks for oxycodone 'just for the weekend.' He also mentions that his wife, a patient of the practice, is out of the Vicodin that 'the other doctor always calls in' and asks Dr. Boone to phone it to the pharmacy so she does not have to drive in. Dr. Boone has not opened the state prescription monitoring database, has no records for the wife in front of him, and is scheduled to leave at 5:00. The office manager says, 'Just do the oxycodone - he'll trash us in the reviews otherwise.'
1. Should Dr. Boone write the oxycodone prescription? Work through indication, monitoring obligations, and documentation.
Read the worked answer
Not on this record, and probably not at all.
- Indication first. Pain from a 6 mm abrasion is normally managed with a bandage lens, cycloplegia, a topical NSAID (with the usual cautions), oral NSAID or acetaminophen, and a 24-hour recheck. A Schedule II opioid for this injury is outside ordinary practice.
- The patient's 'hydrocodone never works' is a scripted phrase, not a clinical finding; combined with a weekend request and a specific drug named, it belongs in the record as a red flag, not as a reason to escalate.
- If an opioid is genuinely contemplated: query the state prescription monitoring database before prescribing a Schedule II agent (Kentucky's KASPER system), document the query and result, screen for concurrent sedatives and history, limit quantity, and write no refills.
- The office manager's review argument is a business rationale, which is precisely what must not drive a controlled-substance decision.
- Then document the refusal, the alternative plan, warning signs to return for, and how to reach the on-call doctor overnight. A documented conservative plan is defensible; an undocumented script is not.
2. How should Dr. Boone handle the request to call in the wife's hydrocodone?
Read the worked answer
Decline the phone-in.
- She is not his patient of record at this encounter: he has no chart, no indication, no dose history, no allergies, and no evidence the prior prescription is current or appropriate. Phoning a controlled substance on that basis is prescribing blind.
- Prescribing for someone based on a spouse's request also invites the appearance of prescribing to accommodate a family unit rather than a patient, and board rules and ethics codes restrict self-prescribing and prescribing for family and close associates for good reason.
- Correct handling: explain that she needs to be seen or that the prescribing doctor must be reached; offer to contact the covering/primary OD, or to have her seen Monday; if pain is urgent, direct her to urgent care. Document the request, the reasoning, and the alternative offered.
- Note the structural risk: a controlled-substance entry in the record and the state database would carry his DEA number and name permanently, and the pharmacy record would contradict any later claim that he never wrote it.
3. The practice's written policy says controlled substances are only prescribed after a documented exam and a database check. What should Dr. Boone verify about that policy before his next shift, and why does it matter to the board?
Read the worked answer
Verify that the policy is operational, not decorative.
- Ask where the database query is recorded (a checkbox, an imported report, a dated note), who has delegate access, and what happens when the system is down at 4:40 on a Saturday. A policy that cannot be executed on a Saturday shift is a policy that invites violations.
- Confirm the practice's registration and storage requirements: who holds the DEA registration, whether the practice handles stock or only prescriptions, and how prescription pads and e-prescribing credentials are secured against staff misuse.
- Board exposure runs on records. In a disciplinary matter the question is not what the doctor remembers but what the chart shows: the query, the indication, the quantity, the counseling, and the follow-up interval.
- Finally, confirm coverage arrangements in writing - an on-call doctor who cannot see the chart cannot responsibly authorize anything, and the covering doctor inherits the liability for anything signed during the shift.