Skip to main content

Table 1 SUD Documentation in specialty and general medical setting

From: Confidentiality protections versus collaborative care in the treatment of substance use disorders

Specialty SUD provider in federally-assisted SUD program

Documentation and explanation

- Patient schedules an appointment with a SUD clinic because he is concerned about his alcohol use.

The SUD counselor documents the details of the patient’s visit in the SUD clinic notes. These notes are protected by 42 CFR Part 2 and are therefore not accessible to others outside the program (in particular the patient’s primary care provider), without a specific release of information from the patient unless there is a qualifying medical emergency or an established QSOA exists.

- Patient completes a brief assessment interview and then meets with his counselor.

- Patient and his counselor discuss the patient’s goals for treatment, and patient is encouraged to attend weekly SUD sessions. Patient is not actively withdrawing from alcohol, so counselor decides that patient does not to attend a detoxification center.

- Patient asks if there are medications to help him deal with cravings, but counselor indicates he does not have prescription privileges. Patient is encouraged to ask his primary care provider about the use of naltrexone.

Medical Provider in Emergency Room

Documentation

- Patient is asked about his alcohol and drug use as part of a visit to an emergency room for a traumatic injury. Patient indicates his injury occurred while intoxicated and voices concern about drinking.

Provider documents the details of the patient’s visit, including the patient’s SUD diagnosis and history of drinking. This information is not protected by 42 CFR Part 2 because the provider’s primary function did not include the provision of substance use services nor did the interaction take place in an identified substance-focused unit.

- Provider (general medical provider) assesses substance use history and diagnoses the patient with alcohol dependence.