Documentation and Record Keeping Flashcards
6 cards from real CAC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Documentation and Record Keeping flashcards as text
A counselor is subpoenaed for a client's records. The MOST appropriate first step is to:
Answer: Consult with a supervisor or attorney before releasing any records
A subpoena alone is not a court order compelling release; consulting legal counsel first ensures the counselor responds appropriately while protecting client rights.
What is the purpose of an 'accounting of disclosures' under HIPAA?
Answer: To provide clients with a record of when and to whom their PHI was disclosed without authorization
Clients have the right to request an accounting of certain disclosures of their PHI made without their consent, such as for public health reporting.
Which statement about electronic health records (EHR) and 42 CFR Part 2 is accurate?
Answer: EHR systems must be configured to segment and restrict SUD records from being shared without specific Part 2 consent
Electronic records containing SUD information must be segmented and access-controlled within EHR systems to prevent unauthorized disclosure in violation of 42 CFR Part 2.
Critical incidents (such as a client's suicide attempt or overdose) must be documented in the clinical record to:
Answer: Create an accurate account of events, actions taken, and follow-up plan for legal and clinical purposes
Thorough critical incident documentation creates a factual record of the event, the counselor's response, and the care plan going forward, which is essential for safety, legal protection, and quality improvement.
Which type of progress note is MOST useful for documenting a client's presentation, the counselor's interventions, and the client's response to those interventions in a single session?
Answer: BIRP note (Behavior, Intervention, Response, Plan)
BIRP notes are structured specifically to document the client's Behavior, the counselor's Intervention, the client's Response, and the next Plan — ideal for capturing session dynamics.
A client requests amendments to their clinical record because they believe it contains inaccurate information. Under HIPAA, the provider may deny this request if:
Answer: The record was not created by the provider, or the provider believes the record is accurate
HIPAA permits providers to deny amendment requests when the information was created by another source or when the provider determines the record is accurate and complete.