1. Maintain the patientâ??s privacy and confidentiality.

  • In general, maintain confidentiality unless the patient gives consent to a specific communication.

  • Under specific clinical circumstances, confidentiality may be attenuated to address the safety of the patient and others.

  • According to the Health Insurance Portability and Accountability Act (HIPAA), information from medical records may be released without a specific consent form for purposes of "treatment, payment, and health care operations." Otherwise, patients must sign an authorization form.

  • When releasing information to third-party payers (e.g., for utilization review or preauthorization decision), it may be important to request specific rather than blanket consent from the patient.

  • Psychotherapy notes have special protection under HIPAA.

  • Release of information about individuals evaluated or treated for substance use disorders is governed by the provisions of 42 CFR §2.11


2. Address legal and administrative issues.

  • When a patient is admitted to a hospital or other residential setting, clarify legal status and establish whether the admission is voluntary or involuntary.

  • Determine if the patient gives or withholds consent to evaluation and treatment.

  • Determine if the patient is able to make treatment-related decisions and whether an advance directive (e.g., concerning psychiatric or end-of-life treatment) has been executed.

  • If fiscal and administrative issues constrain treatment options, inform the patient, family, and others, including third-party payers, and attempt to find alternatives.


3. Understand and address the needs of patients from special populations.

  • Evaluation of elderly patients or patients with medical conditions may emphasize general medical history, cognitive mental status, and level of functioning.

  • Evaluation of incarcerated persons may emphasize legal history, previous episodes of incarceration, and alcohol and substance use history. Risk assessment is crucial, because suicide is one of the leading causes of death in correctional settings.

  • In overcoming mistrust and fear, engagement of homeless persons over numerous, brief, and seemingly casual interactions in nonclinical settings may precede a formal evaluation.

  • Use professionally trained interpreters with mental health experience, when available, for evaluation of patients with limited English proficiency and those who are deaf or have severely limited hearing and who know a sign language.

  • Evaluation of persons with mental retardation may emphasize behavioral observations or functional measures, depending on the patient'€™s ability to understand questions and report on his or her own mental experiences. Co-occurring general medical conditions are often undetected in adults with mental retardation.


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