CAC Documentation and Record Keeping

Question 1

Which type of progress note format structures documentation around Subjective, Objective, Assessment, and Plan?

Accepted Answer

SOAP note

Answer

DAP note

Answer

BIRP note

Answer

PIE note

Question 2

Under HIPAA, clients have the right to:

Accepted Answer

Access and obtain a copy of their own protected health information (PHI)

Answer

Demand that providers delete all of their records

Answer

Share their records with any third party without restrictions

Answer

Prevent providers from using any information in their treatment

Question 3

Which principle requires that clinical documentation be completed as close to the time of service as possible?

Accepted Answer

Timeliness

Answer

Accuracy

Answer

Completeness

Answer

Legibility

Question 4

A DAP progress note includes which three sections?

Accepted Answer

Data, Assessment, Plan

Answer

Diagnosis, Assessment, Prognosis

Answer

Description, Analysis, Progress

Answer

Data, Action, Progress

Question 5

What does 'confidentiality' in addiction counseling protect?

Accepted Answer

Information shared by the client in the course of treatment from unauthorized disclosure

Answer

The counselor from liability when clients relapse

Answer

The identity of the counselor from public disclosure

Answer

Information shared between counselors in supervision

Question 6

Which type of release of information form is required specifically for substance use disorder records under 42 CFR Part 2?

Accepted Answer

A consent form that specifies the program, recipient, purpose, what is to be disclosed, and expiration date

Answer

A standard HIPAA authorization form

Answer

A verbal consent documented in the chart

Answer

A blanket release signed at intake for all future disclosures