Illicit Substance Screening: Documentation

To demonstrate that they are implementing a policy that meets the national standards for quality, an organization needs to maintain appropriate documentation of screenings.

It is recommended that your documentation include:

• Name of the resident
• Date of the screening
• Type of screening – for example, if this is an initial move-in screening, a screening based on suspicion of use, a follow-up screening or a random screening
• The type of screening – what screening method was used
• The results of the screenings – if they revealed substance use or not, or if they were inconclusive
• Any other observations and notes
• Name of the staff member who is overseeing the screening
• Resident acknowledgement and consent to perform the screening OR documentation of the resident’s refusal to participate in the screening