ADM Documentation & Record Keeping 5

Question 1

When a patient on MOUD dies, the prescribing physician's documentation responsibilities include:

Accepted Answer

Recording the date of death, circumstances if known, and any required reporting to DEA or state agency

Answer

Upon patient death, clinicians must document the date and circumstances, notify relevant agencies (e.g., DEA for controlled substances), and retain records per applicable law.

Question 2

Which of the following BEST describes the purpose of a biopsychosocial assessment in addiction medicine documentation?

Accepted Answer

To capture the full context of a patient's substance use across biological, psychological, and social domains for treatment planning

Answer

The biopsychosocial assessment comprehensively characterizes the patient's condition across all relevant domains to guide individualized treatment planning.

Question 3

A patient verbally authorizes a phone call to their spouse about their treatment. Under 42 CFR Part 2, this verbal authorization is:

Accepted Answer

Insufficient — written consent meeting Part 2 criteria is required

Answer

42 CFR Part 2 requires a written consent form meeting specific criteria; verbal authorization alone is not sufficient for disclosure.

Question 4

Mandatory reporting of suspected child abuse in an SUD treatment setting:

Accepted Answer

Is required regardless of 42 CFR Part 2 protections and supersedes them

Answer

State mandatory child abuse reporting laws are not preempted by 42 CFR Part 2, and clinicians must report regardless of the patient's SUD treatment status.

Question 5

In addiction medicine, a 'treatment episode' for documentation and administrative purposes begins:

Accepted Answer

At admission and ends at discharge, transfer, or death

Answer

A treatment episode is formally defined from admission through discharge, transfer, or death, and this period frames all clinical documentation obligations.

(ADM) Board Certified Addiction Medicine Specialist Practice Test

(ADM) Board Certified Addiction Medicine Specialist Practice Test

ADM Documentation & Record Keeping 5