Improving Treatment for Drug-Exposed Infants
Treatment Improvement Protocol (TIP) Series 5

Compliance with Federal Guidelines For Confidentiality

Since confidentiality regulations vary among the States (State regulations can be more stringent than Federal regulations), it is important that each agency ensure that internal policies are in compliance with both Federal and State regulations on confidentiality and patient records. Once compliance is ensured through the development of agency confidentiality policies, a process of QA monitoring can be developed that routinely reviews a sample of all program records. The results of monitoring and actions taken to correct problems and improve service must be documented. Some examples of monitoring are:

• Ensuring that there is documentation of providers informing patients of their right to confidentiality, and to information concerning laws relating to court involvement.
• Ensuring that there is documentation that providers inform patients of all laws as they relate to all areas that affect individuals who are receiving services.
• Ensuring that there is a written informed consent on file whenever there are discussions concerning the patient with individuals or organizations outside the treatment facility.
• Ensuring that the written informed consent is time-limited, content-specific, person-to-person, signed, and witnessed. A sample consent form is included; see Exhibit 8.