Standards › Standard 38 › Policies
Policy · SUB-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 38.4
At a glance
- Information about a person’s substance use is confidential.
- It is shared only with the person’s consent or where the law allows.
- Each disclosure is recorded with the person, the reason and the date.
- Access to records is limited to staff who need it.
- Stop and get help straight away if: information about substance use is disclosed to a third party with no consent and no legal basis.
1. Purpose
To protect people who use substances from harm caused by disclosure, and to keep their trust (38.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A person who uses substances may fear arrest or stigma if their information is shared. Keeping it confidential, and sharing it only with consent or where the law requires, keeps them coming back to care.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Owns the confidentiality policy and approves the disclosure rules | Board or governing body |
| All staff | Keep information confidential and record each disclosure | Clinical director |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Protect.
- Keep records under access controls limited to staff who need them.
Key point: Protected.
Step 2. Check consent.
- Before any disclosure, check the person’s consent or the legal basis (PHC-FRM-001).
Key point: Checked.
Step 3. Record.
- Record each disclosure with the person, the reason and the date.
Key point: Recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Disclosures with consent or legal basis recorded | 100% | Quarterly | Clinical director | Escalate to the board |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| PHC-FRM-001 | Shared record access check (existing) | Form |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (2009), the WHO Guidelines on HIV and harm reduction for people who inject drugs, and the ASF Ambulatory standard for addiction services. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)