University of California, San Francisco at San Francisco General Hospital, Bldg 20, Ste, 2100, Rm 2127 1001 Potrero Avenue, San Francisco, CA 94110, USA.
Addict Sci Clin Pract. 2013 Aug 26;8(1):13. doi: 10.1186/1940-0640-8-13.
Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients' primary and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what care is provided and the setting where the patient is treated. This article explores the special protections for substance abuse documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for more knowledge about how to harmonize treatment in the SUD and primary care systems.
在应对患者保密问题时，联邦资助的物质使用障碍（SUD）治疗项目的从业者面临着越来越复杂的决策。最近的政策变化旨在使治疗更加普及和便捷，这对美国的 SUD 治疗服务产生了影响。电子健康记录的增加为患者的初级保健和 SUD 护理提供者之间提供了更快速和全面的沟通机会，同时促进了协作式护理环境。这种向协作式护理的转变因 SUD 治疗计划中 SUD 文档所获得的特殊保护而变得复杂，这些特殊保护因所提供的护理以及患者接受治疗的环境而异。本文探讨了物质滥用文档的特殊保护、治疗文档中的差异、在临床实践中处理这些问题的方法，以及对如何协调 SUD 和初级保健系统治疗的更多了解的需求。
