Alcohol and Drug Counselor Clinical Documentation and Confidentiality Flashcards
7 cards from real CADC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Alcohol and Drug Counselor Clinical Documentation and Confidentiality flashcards as text
The 'minimum necessary' standard under HIPAA requires counselors to:
Answer: Disclose only the information needed to accomplish the intended purpose
HIPAA's minimum necessary standard limits disclosures to the least amount of protected health information needed to fulfill the purpose of the request.
Which of the following is an example of a 'covered entity' under HIPAA?
Answer: A substance abuse treatment program that transmits health information electronically
A substance abuse treatment program that electronically transmits health information for billing is a covered entity subject to HIPAA regulations.
A treatment record amendment request from a client should be:
Answer: Acknowledged and responded to, with the client's request added to the record if denied
Under HIPAA, clients have the right to request amendments; if denied, the denial must be documented and the client's disagreement noted in the record.
Which of the following BEST describes a Confidential Communication Request (CCR) under 42 CFR Part 2?
Answer: A client's request that communications be sent to an alternate address or by alternate means
A Confidential Communication Request allows clients to ask that sensitive communications be directed to a location or method that protects their privacy.
Documentation errors in a clinical record should be corrected by:
Answer: Drawing a single line through the error, initialing, dating, and writing the correct entry
Proper error correction requires a single strikethrough so the original entry remains legible, followed by initials, date, and the correct information.
Under 42 CFR Part 2, which of the following is permitted WITHOUT patient consent?
Answer: Reporting suspected child abuse to child protective services as required by state law
42 CFR Part 2 contains an exception allowing mandated reporters to report child abuse or neglect without patient consent when state law requires it.
A client's treatment plan should be reviewed and updated at minimum:
Answer: According to program policy, regulatory requirements, and whenever significant changes occur
Treatment plans must be reviewed regularly per program policy and regulatory standards, and updated whenever there is a significant change in the client's status or goals.