Substance abuse documentation confidentiality - Research Paper Example

Substance Abuse Documentation Confidentiality North Carolinas requirements regarding documentation of adherence to confidentiality from state division of addiction or substance abuse servicesConfidentiality refers to any information of an individual under service of s facility received in connection with performance of a function of the facility. The substance abuse counsellor must work in the best interest of clients, and should take it as a primary obligation. The role of protecting the rights of the client under confidentiality must not disclose any confidential information acquired through practice, teaching or investigation with any executed consent (Fang & Applegate, 1998).

The documentation on confidentiality sets the requirements for the people collecting, disseminating and storing information about individuals served by the facilities. According to 10A NCAC 26B .0102, the state, individuals or area facilities with access to confidential information must take the affirmative measures in safeguarding such information. Any confidential information must not be released, except in accordance to G.S 122C-51 through the 122C-56. The release of confidential information regarding substance abusers must be based on federal regulations of the part 2 of 42 C.F.R.

The confidentiality of records for drug and alcohol abusers adopted by the G.S. 150B-14(c) must be pursued unless in case of restrictive rules (Ganley, 2005).Each area within the facilities of the state maintaining confidential information record must provide a secure place for storing the records. Also, they must develop the written policies and procedures on controlled access for the records. All area of the state must ensure authorized access of such records. The director in each state facility must ensure the presence of the clinical staff members to protect and explain the records when the legal person of the client demands the review of the records.

Delegated employees develop the procedures and policies on the provision of safeguards to enhance controlled access of such information (Martin & Moracco, 2008).The director of the state facility must ensure that all people involved in handling confidential information know the terms and conditions provided under G.S. 122C-52 through to 122C-56, and the facility must develop written procedures and policies based on the rules. The facility must provide trainings to all individual authorised access of confidential information.

The individual in training must indicate their understanding of the governing requirements confidentiality through signing a statement of compliance and understanding (Ganley, 2005).Employees must sign the statement upon employment and in case the revisions happens to the requirements. The regulations require treatment of information received from other facilities or agencies regarded as confidential. The confidential information must only be disclosed to the next of kin with the legitimate role in therapeutic services offered, or any other person designated as legally responsible by the client based on G.S.122C-55(j) and (l).

The employees of the state facility must never release confidential information without consent of release form. The disclosure without authorization must be based on G.S. 122C-52. Unless revoked by legal persons representing the client or the client himself, consent of release of information remains valid for a period of one year. The patient must sign the consent for release of any confidential information on assessment for dependency, addiction and substance abuse (Martin & Moracco, 2008).

The laws provide for protection of the reporter from potential actions from the alleged perpetrator. However, the disclosure of reporter’s name may only happen through the order of court release. All the information on treatment or diagnosis of substance abuse must be taken away from the case record prior to the review unless in the event of valid consent of release (Fang & Applegate, 1998). ReferencesFang, W., & Applegate, R. (1998). The Development of Substance-abuse Curricular Content by Five North Carolina Schools.

Academic Medicine 73(10), 1049-43.Ganley, O. (2005). Outcome Study of Substance Impaired Physicians and Physician Assistants Under Contract with North Carolina Physicians Health Program for the Period 1995-2000. Journal of Addictive Diseases 24(1), 1-12.Martin, S., & Moracco, J. (2008). Substance Abuse Issues Among Women in Domestic Violence Programs: Findings From North Carolina. Violence Against Women 14(9), 985-97.