ADM Documentation & Record Keeping 3

Question 1

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?

Accepted Answer

Patient provides written consent authorizing disclosure to the ED

Answer

Written patient consent naming the recipient and the purpose is the standard pathway for disclosure under 42 CFR Part 2.

Question 2

In addiction medicine, the term 'concurrent documentation' refers to:

Accepted Answer

Recording clinical information at the time of or immediately after the encounter

Answer

Concurrent documentation means capturing clinical information during or directly after the patient encounter to maximize accuracy.

Question 3

Which element is REQUIRED in a valid 42 CFR Part 2 consent form?

Accepted Answer

Name or description of the recipient to whom disclosure is made

Answer

A valid Part 2 consent must identify the specific person or entity to whom disclosure is authorized.

Question 4

HIPAA's minimum necessary standard requires that disclosures of PHI be limited to:

Accepted Answer

Only what is reasonably needed to accomplish the intended purpose

Answer

The minimum necessary standard restricts disclosures to the least amount of PHI needed for the specific purpose of the disclosure.

Question 5

When a patient declines to sign a PDMP query acknowledgment form, the prescriber should:

Accepted Answer

Document the refusal, consult the PDMP anyway per state law, and assess clinical implications

Answer

PDMP queries are typically a legal prescribing obligation; the refusal and clinical rationale must be documented regardless of patient preference.

(ADM) Board Certified Addiction Medicine Specialist Practice Test

(ADM) Board Certified Addiction Medicine Specialist Practice Test

ADM Documentation & Record Keeping 3