Addiction Medicine Certification Clinical Documentation & Records 2

Question 1

Under 42 CFR Part 2, a patient's consent for disclosure of SUD records must include which element?

Accepted Answer

The name or title of the person authorized to make the disclosure

Answer

42 CFR Part 2 requires consent to identify the individual or organization authorized to make the disclosure, among other required elements.

Question 2

Which document is required before a substance use disorder treatment program can respond to a law enforcement subpoena under 42 CFR Part 2?

Accepted Answer

A court order that meets specific 42 CFR Part 2 criteria

Answer

42 CFR Part 2 requires a special court order meeting specific criteria, not just any subpoena, before SUD records may be disclosed to law enforcement.

Question 3

What is the primary purpose of a biopsychosocial assessment in addiction medicine documentation?

Accepted Answer

To comprehensively evaluate biological, psychological, and social factors influencing the patient's SUD

Answer

A biopsychosocial assessment captures the interplay of biological vulnerabilities, psychological factors, and social determinants relevant to the patient's substance use disorder.

Question 4

When documenting a patient's refusal of recommended treatment in addiction medicine, the clinician should record:

Accepted Answer

The refusal, information provided about risks, and the patient's stated reasons

Answer

Informed refusal documentation should capture what the patient refused, the risks communicated, and the patient's reasons to protect both patient and provider.

Question 5

In an addiction medicine EHR, a 'problem list' entry for opioid use disorder should use which coding system?

Accepted Answer

ICD-10-CM

Answer

Diagnoses including opioid use disorder are coded using ICD-10-CM (e.g., F11.20) for medical records and billing purposes.

Addiction Medicine Certification Practice Test

Addiction Medicine Certification Practice Test

Addiction Medicine Certification Clinical Documentation & Records 2