Health Information Technologies and Processes

Substance Abuse Records

  • 1.  Substance Abuse Records

    Posted 10-03-2019 08:05
    We are in the process of pioneering a substance abuse treatment program for pregnant mothers.  The goal is to produce a healthy newborn and the mother be stable so she will be able to keep the newborn.  My issue is, how do we keep the substance abuse treatment part of the record separate from the delivery record and how to handle this for ROI.  The mother will be receiving treatment during the delivery visit so that will be intermingled with their healthcare record.  I can't lock these visits because it would make them inaccessible in the event they returned for medical treatment.  We are Meditech 5.67.  I think we may be one of the first providers to start a program like this so I really don't know who to reach out to.  If there is anyone out there with this type of program, please reach out to me.  Thanks in advance.

    Pamela Gonterman
    Director of His/Coding

  • 2.  RE: Substance Abuse Records

    Posted 11-16-2019 17:44
    Hello Pamela,

    We use Meditech 6.15 and have a Chemical Dependency program but it's separate from the inpatient or delivery visit. I'm not sure if any of our patients received treatment while being pregnant.  Our Chemical Dependency visits are confidential and only HIM and the Chemical Dependency counselor have access to view those notes. You  might ask your Meditech specialist how to maintain the substance abuse documentation as confidential while the remaining delivery documentation is available for viewing by other providers.


    Glenda Rakes
    HIM Director/Privacy Officer
    Northern Montana Health Care