Alcohol and Drug Counselor Clinical Documentation and Confidentiality Flashcards

A counselor suspects a colleague is accessing client records without a clinical need. The MOST appropriate first action is to:

Answer: Report the concern to the supervisor or privacy officer per program policy

Suspected unauthorized access to records should be reported through proper channels — typically to a supervisor or HIPAA privacy officer — for investigation.

Which of the following must be included in a valid 42 CFR Part 2 consent form?

Answer: The name of the person or organization authorized to make the disclosure and the recipient

A valid 42 CFR Part 2 consent must identify who may disclose the information, to whom, the purpose, and the scope of what may be shared.

The Duty to Warn (Tarasoff) obligation most commonly requires a counselor to:

Answer: Take reasonable steps to protect an identifiable third party from a credible, specific threat

Tarasoff and similar duty-to-warn laws apply when a client makes a credible, specific, and serious threat against an identifiable victim, requiring protective action.

A client involved in a drug court program signs a consent allowing the treatment program to share information with the drug court. Under 42 CFR Part 2, this arrangement is:

Answer: Permissible because the client has provided valid written consent

With a valid patient consent form meeting 42 CFR Part 2 requirements, treatment programs may share information with drug courts and other criminal justice entities.

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

Answer: To gather comprehensive information about biological, psychological, and social factors influencing the client's substance use

A biopsychosocial assessment collects holistic information across biological, psychological, and social domains to inform accurate diagnosis and individualized treatment planning.

When a client is transferred between two substance abuse treatment programs, information sharing is permitted under 42 CFR Part 2 if:

Answer: The client provides written consent authorizing the transfer of records

A transfer of substance abuse treatment records to another program requires the client's written consent that meets all 42 CFR Part 2 requirements.

Late entries in clinical documentation should be:

Answer: Clearly marked as late entries with the date and time of the actual writing

Late entries must be labeled as such with the actual date and time of writing to maintain the accuracy and integrity of the clinical record.