1 In your own words, describe your understanding of confidentiality

1 In your own words, describe your understanding of confidentiality

Be sure to discuss the role of HIPPA and CFR 42, part 2 (summary located in the module notes) in providing protection of client information.

2 Describe what you feel professionalism in the counseling field should be. If a counselor you work with violates an ethical standard, what is your responsibility according to the NAADAC Code of Ethics?

3 Many students who take this course do so because they want to become a counselor. If this is true for you, write a short essay on why you want to be a counselor, what population of clients you think you would like to work with, and what special knowledge, skills, and attitudes you bring with you to the counseling profession. If you are not planning on becoming a counselor, discuss the knowledge, skills, and attitudes you feel a good counselor needs to have and why.

4 Based on all you have learned in this class this semester, pick one topic and discuss how it has impacted how you think and feel about substance abuse and addiction. Please give this some thought and make this a meaningful entry.

NAADAC Code of Ethics Principle 1: Non-Discrimination I shall affirm diversity among colleagues or clients regardless of age gender, sexual orientation, ethnic/racial background, religious/spiritual beliefs, marital status, political beliefs, or mental/physical disability. • I shall strive to treat all individuals with impartiality and objectivity relating to all based solely on their personal merits and mindful of the dignity of all human persons. As such, I shall not impose my personal values on my clients. • I shall avoid bringing personal or professional issues into the counseling relationship. Through an awareness of the impact of stereotyping and discrimination, I shall guard the individual rights and personal dignity of my clients. • I shall relate to all clients with empathy and understanding no matter what their diagnosis or personal history. Principle 2: Client Welfare I understand that the ability to do good is based on an underlying concern for the well being of others. I shall act for the good of others and exercise respect, sensitivity, and insight. I understand that my primary professional responsibility and loyalty is to the welfare of my clients, and I shall work for the client irrespective of who actually pays his/her fees. • I shall do everything possible to safeguard the privacy and confidentiality of client information except where the client has given specific, written, informed, and limited consent or when the client poses a risk to himself or others. • I shall provide the client his/her rights regarding confidentiality, in writing, as part of informing the client of any areas likely to affect the client’s confidentiality. • I understand and support all that will assist clients to a better quality of life, greater freedom, and true independence. • I shall not do for others what they can readily do for themselves but rather, facilitate and support the doing. Likewise, I shall not insist on doing what I perceive as good without reference to what the client perceives as good and necessary. • I understand that suffering is unique to a specific individual and not of some generalized or abstract suffering, such as might be found in the understanding of the disorder. I also understand that the action taken to relieve suffering must be uniquely suited to the suffering individual and not simply some universal prescription. • I shall provide services without regard to the compensation provided by the client or by a third party and shall render equally appropriate services to individuals whether they are paying a reduced fee or a full fee. Principle 3: Client Relationship I understand and respect the fundamental human right of all individuals to selfdetermination and to make decisions that they consider in their own best interest. I shall be open and clear about the nature, extent, probable effectiveness, and cost of those services to allow each individual to make an informed decision of their care. • I shall provide the client and/or guardian with accurate and complete information regarding the extent of the potential professional relationship, such as the Code of Ethics and professional loyalties and responsibilities. • I shall inform the client and obtain the client’s participation including the recording of the interview, the use of interview material for training purposes, and/or observation of an interview by another person. Principle 4: Trustworthiness I understand that effectiveness in my profession is largely based on the ability to be worthy of trust, and I shall work to the best of my ability to act consistently within the bounds of a known moral universe, to faithfully fulfill the terms of both personal and professional commitments, to safeguard fiduciary relationships consistently, and to speak the truth as it is known to me. • I shall never misrepresent my credentials or experience. • I shall make no unsubstantiated claims for the efficacy of the services I provide and make no statements about the nature and course of addictive disorders that have not been verified by scientific inquiry. • I shall constantly strive for a better understanding of addictive disorders and refuse to accept supposition and prejudice as if it were the truth. • I understand that ignorance in those matters that should be known does not excuse me from the ethical fault of misinforming others. • I understand the effect of impairment on professional performance and shall be willing to seek appropriate treatment for myself or for a colleague. I shall support peer assistance programs in this respect. • I understand that most property in the healing professions is intellectual property and shall not present the ideas or formulations of others as if they were my own. Rather, I shall give appropriate credit to their originators both in written and spoken communication. • I regard the use of any copyrighted material without permission or the payment of royalty to be theft. Principle 5: Compliance with Law I understand that laws and regulations exist for the good ordering of society and for the restraint of harm and evil, and I am aware of those laws and regulations that are relevant both personally and professionally and follow them, while reserving the right to commit civil disobedience. • I understand that the determination that a law or regulation is unjust is not a matter of preference or opinion but a matter of rational investigation, deliberation, and dispute. • I willingly accept that there may be a penalty for justified civil disobedience, and I must weigh the personal harm of that penalty against the good done by civil protest. Principle 6: Rights and Duties I understand that personal and professional commitments and relationships create a network of rights and corresponding duties. I shall work to the best of my ability to safeguard the natural and consensual rights of each individual and fulfill those duties required of me. • I understand that justice extends beyond individual relationships to the community and society; therefore, I shall participate in activities that promote the health of my community and profession. • I shall, to the best of my ability, actively engage in the legislative processes, educational institutions, and the general public to change public policy and legislation to make possible opportunities and choice of service for all human beings of any ethnic or social background whose lives are impaired by alcoholism and drug abuse. • I understand that the right of confidentiality cannot always be maintained if it serves to protect abuse, neglect, or exploitation of any person or leaves another at risk of bodily harm. Principle 7: Dual Relationships I understand that I must seek to nurture and support the development of a relationship of equals rather than to take unfair advantage of individuals who are vulnerable and exploitable. • I shall not engage in professional relationships or commitments that conflict with family members, friends, close associates, or others whose welfare might be jeopardized by such a dual relationship. • Because a relationship begins with a power differential, I shall not exploit relationships with current or former clients for personal gain, including social or business relationships. • I shall not under any circumstances engage in sexual behavior with current or former clients. • I shall not accept substantial gifts from clients, other treatment organizations, or the providers of materials or services used in my practice. Principle 8: Preventing Harm I understand that every decision and action has ethical implication leading either to benefit or harm, and I shall carefully consider whether any of my decisions or actions has the potential to produce harm of a physical, psychological, financial, legal, or spiritual nature before implementing them. • I shall refrain from using any methods that could be considered coercive such as threats, negative labeling, and attempts to provoke shame or humiliation. • I shall make no requests of clients that are not necessary as part of the agreed treatment plan. • I shall terminate a counseling or consulting relationship when it is reasonably clear that the client is not benefiting from the relationship. • I understand an obligation to protect individuals, institutions, and the profession from harm that might be done by others. Consequently, I am aware that the conduct of another individual is an actual or likely source of harm to clients, colleagues, institutions, or the profession, and that I have an ethical obligation to report such conduct to competent authorities. Principle 9: Duty of Care I shall operate under the principle of Duty of Care and shall maintain a working/therapeutic environment in which clients, colleagues, and employees can be safe from the threat of physical, emotional or intellectual harm. • I respect the right of others to hold opinions, beliefs, and values different from my own. • I shall strive for understanding and the establishment of common ground rather than for the ascendancy of one opinion over another. • I shall maintain competence in the area of my practice through continuing education, constantly improving my knowledge and skills in those approaches most effective with my specific clients. • I shall scrupulously avoid practicing in any area outside of my competence. Updated December 8, 2004

Section I – Principles for Writing HIPAA Notices of Privacy Practices in Plain English
Principles for Plain Language Privacy Notices Introduction

You are writing a HIPAA Privacy Notice. Your dilemma is: It’s a legal document that must meet the intent and letter of the law, but it also has to be in Plain Language.

If you use these Principles you will:

• be able to write it more quickly and easily,
• have fewer revisions and editions.

These Principles are intended as an aid to writers of Privacy Notices and are not necessarily a guarantee to meet all of the legal requirements of HIPAA. This guidance is intended solely to provide some helpful hints for making a notice of privacy practices more readable. It does not create any binding requirements for how a notice of privacy practices must be phrased or structured.

The Principles are presented in a “progressive format.” That is, the Plain Language process is arranged to flow from the most general to the more detailed. There are advantages to using the same format in your Privacy Notice. Sections in the Principles are:

Section 1. Introduction and preamble (an overview)
Section 2. Principles (individual principles)
Section 3. Examples for each principle using HIPAA content. (details)
Section 4. Appendices (very specific details)

The Privacy Rule encourages, but does not require, writers to develop a “layered” notice. The Preamble to the Final Modification of August 14, 2002, Federal Register page 53243, says that a two layered notice would satisfy notice requirements. The first layer would be a short notice that summarizes individual’s rights and other information. The second layer would be longer and include all the elements required by the Rule.

It is possible to combine the “layered” format with the “progressive” format, by using the elements of the “progressive” approach in the second, longer, layer.

It is important to remember that the Notice must include all the elements that the Rule requires. You can find the details in the Rule. If you are using the progressive approach the required elements can be integrated in the relevant parts. The required elements are:

• Header with specific language
• Uses and disclosures
• Separate statements for certain uses and disclosures
• Individual rights
• Covered entity’s duties
• Complaints
• Contact

The basis for the Principles is a mix of well known advice for Plain Language. This “mix” is outlined in Suitability Assessment of Materials (SAM).⁽¹⁾ Other resources in health care communication can be found at most State Health Departments.

 

Principles

1. The Content of the Notice
   The HIPAA rules tell us the topics that must be in the Notice. A special highlighted header on the purpose is also required. But the Notice writer is free to arrange the order of the topics. And the rules allow and encourage that other topics may be added. You may want to place topics in the order of your patients’ interest – with the most interesting topic first. After the required statement, the order may be:
2. a) A preamble, including “What good is this Notice to me?” (Examples)
   b) What is a health care record? (Examples.)
   c) Patient Rights. (Examples)
   d) Who can see your record without asking you? (Examples)
   e) Who can’t see your record unless you give a written OK? (Examples)
3. Preamble
   A preamble is helpful before giving the HIPAA content. The reasons:

– Many won’t see any personal benefits of the Privacy policy.
– The very concept of health care records and privacy may not be familiar. (An explanation and visual may be needed to clarify.)
– Many won’t grasp why and what they are asked to sign and what use they can or should make of the Privacy Notice.

Appendix A gives an example of a preamble that covers these points.

Appendix B gives the text of the rules that describes in detail what to include, how to deliver, and other things about the notice.

2. Making the notice easy to read and understand
   The HIPAA rules do not set a goal for readability level, but many States have set goals for health care print materials.⁽²⁾ These range from 4^th to 6^th grade levels. In comparison, many draft Privacy Notices written to date are about 16^th grade (college grad level). (Note: The average readability of this Principles document is at the 8^th grade level.)

You would like the readability of your Notice to be compatible with the reading skill level of your patient population. The average reading skill of adult Americans is about 9^th grade level. For people over 65, and for most minority groups, the average skill levels are lower than 9^th grade. (See Ref. 5 for reading skills by age, gender, ethnic set.)

It is clearly the intent of the rules that patients be able to read and understand the Notice. A suitable readability level is essential, but that is only one of the necessary factors for understanding. Because of the complexity of the Notice content, examples are needed to explain what is meant by many of the privacy statements. In fact, Section 164.520(b) of the rules requires that at least one example be given for certain types of disclosures.

1. To make the Notice easier to read

• Use a conversational style. It is almost always easier to read narrative than more formal styles of writing. (The rules are written in formal/legal style: you must translate them.) For the first draft, write it as you would say it. Tip: If you find it hard to do this, try running a tape recorder while you tell a person the Notice content as best you can from memory or from a simple list of topics. Then transcribe and edit the tape. For example:
  • More Formal Language
    Covered entities must describe the right of patients to make amendment of a protected health record if patient believes the health information is incorrect or incomplete.
    Conversational Style
    If you think there is something wrong or missing in your health record, you can ask that it be changed.
• Use common words. Common words are better known to the public and are often shorter. A Thesaurus of more common words for those found in HIPAA is in Section II. (For these Principles we use OK vs authorization, rules vs regulations, health care records vs protected medical records, etc.)
• Use shorter sentences. Keep the average sentence to about 15 words or less. Try bullets for short lists. (For example, in these Principles the average sentence length is between 15 and 20 words.)
• Avoid hyphens and compound words. These increase readability level. For example: self insured vs self-insured; any one vs anyone.
• Give examples to explain “problem” words. Problem words – if you use them -are often those that describe a concept, a category, or a value judgment (CCVJ). Some words and phrases may be both a category and concept depending on the context. If you use these kinds of words, add an explanation or example to define them. Here are just a few of the problem CCVJ words found in HIPAA:
  For example: “disclosures” usually means showing your health care records to someone outside this organization. This can be to another doctor treating you, or those paying for your treatment, and others.

Concept	Category	Value Judgment
disclosures	disclosures required by law	adequate notice
access	business associates	material changes
authorization	covered entity	significant number
activities	self-insured groups	reasonable effort

• For example: “disclosures required by law” means “When the law demands that we show your health record to other people we will do so. For example, we will report communicable diseases to the appropriate health authorities as required by law. When the law allows us to show your health record to other people, we will show it when there are good reasons to do so. For example, to assist those conducting worthwhile research.”
  For example: “significant number” means -% or more of the population speaks only some other language.
• Use lower case rather than all capital letters . Research tells us that text in all CAPS is harder and slower to read, and harder to understand. The reason: Besides looking at the letters in a word, we recognize words by their shape. For example, ” try” and “medical” are easier to recognize and read than TRY AND MEDICAL.
  With all CAPS the height of the letters is the same, so we lose “shape of the words” as a reading cue. This slows reading speed. For many, by the time they get to the end of a sentence, they may have forgotten what they read earlier in that sentence. Suggested remedy: To give emphasis or prominence, use bold and larger font size with lower case letters (except where grammar calls for a capital letter).
• Assess readability. After drafting your Notice, assess its readability level using one of the many formulas available.

 

1. To improve understanding and to make it “look” easier to read:
   The rules do not specify layouts, fonts, and other factors that can make the Notice look easy to read. But if it looks hard to read, many patients won’t want to read it, won’t bother to read it. And they won’t understand it. Many draft Notices written to date have long lists of items. These look hard to grasp and to remember – and they are. Here are ways to make it look easy to read and easier to understand:

• Allow more white space by using wider margins. Double column of text (like a newspaper format) can also give a more open look. These layout devices will also shorten the line lengths to be closer to 50 to 60 letters and spaces. That is easiest to read.
• Chunk” long lists into smaller bites. Chunking makes the information look less formidable, and helps the reader better understand and remember. Look for logical groupings within the long list. Then place these items under suitable descriptive sub headers. Appendix C gives an example of chunking of one group of HIPAA topics.
• Consider visuals as well as text in your Notice. The legal nature of the HIPAA content and the absence of visuals in the rules do not in any way limit the use of visuals – especially for examples. Visuals can be used to explain a number of the HIPAA concepts. For example, consider the stated HIPAA concept phrase: “a health care record.” Rough sketches of visuals that might be included for explanation are:Figure 1. Your health care record can be all of these:

(Show a doctor holding up an x-ray to a light box.)	(A file folder with lots of papers in. A slot for “Name”___ on the cover.)	(Two sketches of . desk-top computers,with image on screens. Show lightning flash between computers to show linkage.)
An x-ray	A folder of papers	A computer file

• Use large fonts and high contrast. Older readers tend to need larger font sizes. Use at least 12 point font for your Notice. And they need high contrast between ink and paper. For example, black ink on white paper, or black on light yellow paper. Do not use high gloss paper. It has a higher glare.
• Give the context first, before giving the new information. With the context first, it is easier to associate the information with things we already know. If the context is last, we must carry in short term memory all of the preceding information until we get to the end of the sentence. By then, we may have forgotten much of the information that went before.
  Original: Context last – Harder to read: (in italics)
  “We will also provide your physician or a subsequent health care provider with copies of various reports that should assist with your treatment once you are discharged from this hospital.”
  Rewritten: Context first – Easier to read:
  “Once you are discharged from this hospital, your physician or other health care providers will be treating you. We will give copies of your health records to doctors and other health providers to help them in treating you.”

1. Use Visuals that explain and clarify:

Readers should be aware that the Privacy Rule does not require the use of visuals, however, the research tells us that visuals help us understand, and they are a great help to memory. (We remember the face – a visual, but not the name – words). Visuals also “lighten” the page appearance and make it more inviting. For the Privacy Notice, simple visuals could be the examples that clarify the meaning of:

sharing of your record by doctors and nurses treating you

paying for treatment

running the hospital or clinic

telling about other health benefits and services

reminding you of appointments

telling you about treatment choices

including you in the hospital directory

telling family and friends

others

Use simple line drawings. These work best because they convey the image without background clutter. They are also less costly to make and can be made and revised quickly. Even stick figure icons can greatly improve memory.

Cue the viewer: The patient needs to quickly grasp what to look at in the picture. For example, if the visual is to show one doctor disclosing a patient record to another for treatment, consider adding an arrow pointing to the folder they are both sharing. The words, “talking about your record” might be added to the arrow.⁽³⁾

Use action captions: A short, action caption tells what the visual is all about – its key point. For example, if a visual showed an appointment slip, a caption might say something like, “To remind you when to come back.”

With few exceptions, it is best to include a caption with each visual and always locate the caption in the same place with respect to the visual. If the layout of the text and visuals on the page clearly associates the two, then the adjacent text may serve as the caption.

3. Make it suitable for the culture.
   First impressions: First impressions do count on how we accept new things. The rules say nothing about a cover page for the Notices. This gives you, the writer, a chance to create a cover that projects a culture friendly image. Although this is not required by the Privacy rule, you will find it helpful to make sure that your notice responds to the culture of the readers. For example, for a Native American population, consider a cover visual showing a Native American patient. The cover might also show a doctor holding or using a health care record. For a mix of ethnic groups (often the case) show a mix of people from ethnic groups on the cover.

Match the logic, language, experience of the culture: Write your Notice with these three factors in mind. (But to really know if your draft notice is culturally suitable, you will need to pretest your Notice with a small sample of typical adults from that culture. One-to-one pretesting is recommended. Appendix D outlines a pretesting protocol.)

Logic: Each culture has its own logic with respect to health. For example: It is the logic of many ethnic groups that “the doctor knows best” and their logic and belief is never to question such an authority figure – even if they think their record is wrong. One remedy: The Notice may have to take pains to make such questioning easy for the patient (perhaps by modeling some questions) and/or show by example (a visual?) that it is OK to do so.

It is logical to think in the here and now, rather than future possibilities. Thus, it may be hard to grasp the logic of showing a patient’s health record to a funeral director, or to law enforcement. (Does it mean I’m going to die, or be arrested?) For these, and other less likely disclosures, consider grouping them under a sub-header and adding a short explanation. For example: “When law demands or allows us to we would show your health record to other people. Sometimes when there are good reasons to do so, we could show them.”

Language: Although many words and terms used in regulations such as HIPAA need translation for any culture, care must be taken so that terms are correctly used. Many words are best explained by an example. For example: “Health Oversight Authorities” such as health inspectors, and other government people who check our hospitals and clinics.”

Metaphors can be misleading in any culture. For example, one draft Notice says that the health record serves “as a tool for education of health care professionals.” But in millions of minds, tools are things like hammers, saws, drills. They may think, how could the pieces of paper be like those?

Experience: The content of the Notices presupposes a number of special skills in literacy, problem solving, and experience. That is, the reader has to be able to do certain tasks or have some prior knowledge or experience.

For example, the tasks and experience needed for patients to exercise their right to limit disclosure of some part of their health care records include:

1. Understanding that they have a right to do this, and the limits of that right.
   2. Have experience with the process and carry out the required actions. (Write a request, know who to send it to, etc.)
   3. Know how to verify that their request was honored, and protest if it was not.

For each of the Patient Rights, consider doing a simple task analysis similar to that shown above. That will help you to see if your patient population is likely to have the needed experience and skills to exercise those rights. If they do not, then we suggest that additional helpful advice be included. This may be in the Notice itself or in a supplementary piece. Insight into the skills of the US population as a whole, as well as that of several minority groups can be obtained from the National Adult Literacy Survey (NALS).⁽⁴⁾

4. For those with very limited reading skills
   Even the most carefully prepared Privacy Notices are likely to be over the heads of about twenty percent of the adult American population. A copy of the Notice may be given to the patient with the hope that someone at home will read and explain it. Another option is to “tell” the Notice content or use another media. This might be a talk, an audio tape, a pictorial series, or a video tape. For some, an interactive web site may be suitable.⁽⁵⁾ This is not a requirement of the rule, but is something you may want to consider.

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