Documentation & Record Keeping Flashcards
7 cards from real ADM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Keeping flashcards as text
A patient enrolled in an OTP (opioid treatment program) is also receiving care at a hospital ED. For the OTP to share records with the ED, which condition is sufficient under 42 CFR Part 2?
Answer: Patient provides written consent authorizing disclosure to the ED
Written patient consent naming the recipient and the purpose is the standard pathway for disclosure under 42 CFR Part 2.
In addiction medicine, the term 'concurrent documentation' refers to:
Answer: Recording clinical information at the time of or immediately after the encounter
Concurrent documentation means capturing clinical information during or directly after the patient encounter to maximize accuracy.
Which element is REQUIRED in a valid 42 CFR Part 2 consent form?
Answer: Name or description of the recipient to whom disclosure is made
A valid Part 2 consent must identify the specific person or entity to whom disclosure is authorized.
HIPAA's minimum necessary standard requires that disclosures of PHI be limited to:
Answer: Only what is reasonably needed to accomplish the intended purpose
The minimum necessary standard restricts disclosures to the least amount of PHI needed for the specific purpose of the disclosure.
When a patient declines to sign a PDMP query acknowledgment form, the prescriber should:
Answer: Document the refusal, consult the PDMP anyway per state law, and assess clinical implications
PDMP queries are typically a legal prescribing obligation; the refusal and clinical rationale must be documented regardless of patient preference.
A treatment plan must be updated according to SAMHSA standards whenever:
Answer: A significant change in patient status, goals, or treatment occurs
SAMHSA standards require treatment plan updates in response to clinical changes, goal achievement or modification, or changes in level of care.
In an electronic health record (EHR), audit logs serve which primary function related to 42 CFR Part 2 compliance?
Answer: Tracking who accessed or disclosed SUD records and when
Audit logs create an accountable trail of access and disclosures, which is essential for demonstrating compliance with 42 CFR Part 2 restrictions.