QUESTION:
What is the difference between SUD Records and SUD Counseling Notes?

ANSWER FROM HORTYSPRINGER ATTORNEY MOISES A. TONOC BONILLA:
Under 42 CFR Part 2 (“Part 2”), Substance Use Disorder (“SUD”) Records consist of any information, recorded by, created by, received by, or acquired by a Part 2 Program, relating to a patient (e.g., a diagnosis, treatment or referral for treatment information, billing information, emails, or voice mails), including patient identifying information.

“SUD Counseling Notes” are notes that are made by a Part 2 Program provider who is a SUD or mental health professional during a SUD counseling session (or a group, joint, or family SUD counseling session). SUD Counseling Notes are separated from the rest of the patient’s SUD and medical record.

SUD Counseling Notes exclude the following information:

• medication prescription and monitoring;

• counseling session start and stop times;

• the modalities and frequencies of treatment furnished;

• results of clinical tests; and

• any summary of a diagnosis, function status, treatment plan, symptoms, prognosis, and progress to date.

When a patient provides written consent to the use and disclosure of their SUD Record, that consent does not extend to SUD Counseling Notes.  A separate written consent to use and disclose SUD Counseling Notes must be obtained. Moreover, written consent for use or disclosure of SUD Counseling Notes may only be combined with another written consent for use or disclosure of SUD Counseling Notes.

If you have a quick question about this, e-mail us at info@hortyspringer.com.