Columbus County Health Department Substance Abuse Assessment Protocol
Policy and Procedure
Policy Title:
Substance Abuse Assessment Protocol
Program Area:
Maternity, Family Planning, and OB Case Managers,
Policy Identifier:
(optional)
Effective Date:
Approval Date:
Revision
Date(s):
1/23/2007
3/9/2009, 4/20/2015
Approved by:
Kim Smith RN, BSN, MSHCA, Health Director
Approved by:
Hilda Memory RN, BS, MSHA, Director of Nursing
Purpose:
To identify women who use legal and/or illegal substances so that they may be
offered prevention, education, counseling, and referral for assistance.
Definitions: I
Women enrolling in Columbus County Health Department’s Women’s Health
Programs will be screened for substance abuse use through interview. If client is
pregnant a urine screening will be performed after obtaining informed consent. If
substance abuse is identified, information will be offered on the possible adverse
effects of the substance and assistance with treatment options. This is to include
tobacco, alcohol and other drugs.
Responsibilities:
Nurse Practitioners, Family Planning Nurse (PHN III), Maternal Care Coordinator
Procedures:
A. The initial enrollment interview for Maternity, Family Planning, and Maternity
Care Coordination Programs include screening questions for substance abuse
during the initial visit and revisit process with direct observation of the patient
and the patient’s response. The Nurse Midwife/Nurse Practitioners and RN’s
initiate the assessment by utilizing CureMD which includes the information
from the DHHS forms:
 DHHS forms 2814 and 4060-F (family planning)
 Forms 3963A and 3963B (Maternity)
MH and FP
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Columbus County Health Department Substance Abuse Assessment Protocol
Policy and Procedure
 Maternal Health History 3963 Part C-1 and 3963 Part C-2
 Family Planning form 4060M
B. In the event a client’s responses indicate substance abuse:
 The Nurse Practitioner will discuss the potential adverse effects of substance
abuse.
 May be referred to the high risk maternity clinic in Wilmington (Coastal
OB/GYN with signed consent for referral and release of medical records.)
 May be referred for classes (if available) with patient’s consent.
 May be referral to other agencies (Mental Health/Substance Abuse
Counseling) as indicated with patients consent
Subject: Substance Abuse Assessment Protocol
C. On enrollment in Maternity Clinic:
 The client will be informed that urine testing for substance use is a part of
the initial routine clinic testing as indicated.
 The client is asked to sign an informed consent for testing and to share
information from her record according to agency policies.
 If a client declines urine drug screening or referrals, she will be assured that
services will not be altered and information will be appropriately
documented on the problem list and Personal Health Record.
 Client will receive educational material on the effects of substance abuse by
utilizing the DHHS Manual, Responding to Prenatal Substance Use: A
Guide for Local Health Departments. (See attached link)
 The patient will also be notified if she decides to receive services at a later
date it will be available to her.
 The client will need to sign a declination form refusing urine testing.
 In the event of positive results on urine testing, she will be referred for
appropriate follow-up
D. All information and test results are confidential and staff will follow agency
policy in regards to this information.
E. A few of the referral sources for substance abuse are listed below:
 Department of Social Services 910-642-2800
 East Point Behavioral Healthcare 1-800-819-5112
See link attached link for: Columbus and surrounding Counties
(Bladen, New Hanover, Brunswick, and Robeson)
 Perinatal Substance Abuse Project
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Columbus County Health Department Substance Abuse Assessment Protocol
Policy and Procedure
 Families First 910-642-5996 or the Crisis Line 910-641-0444
F. Smoking Cessation policy. See attached link.
G. Confidentiality is maintained per agency policy for all substance use/abuse
issues and release of information/medical records is done in accordance with
local agency policy and Responding to Prenatal Substance Use.(A Guide for
Local Health Departments)
Please note a Consent Form must be signed before any drug screenings are
performed by this agency
Laws and Rules:
Title X
Reference(s):
NCDHHS WH Branch- Forms
MH and FP
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