Documentation and Case Management 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 Documentation and Case Management flashcards as text
Under 42 CFR Part 2, substance use disorder treatment records receive special protection because:
Answer: Disclosure could harm patients by deterring them from seeking treatment
42 CFR Part 2 provides heightened confidentiality protections to encourage individuals to seek SUD treatment without fear of legal consequences.
When documenting a client's discharge summary, which information is MOST important to include for continuity of care?
Answer: Goals achieved, unresolved issues, and aftercare recommendations
A discharge summary must document progress toward goals, remaining needs, and aftercare recommendations to support continuity of care.
A counselor discovers a documentation error in a client's chart from a previous session. The CORRECT way to correct it is to:
Answer: Draw a single line through the error, write the correction, and initial and date it
The standard for correcting medical records is a single line through the error with the correction, initials, and date — never obliterate the original.
Which of the following BEST reflects the broker model of case management?
Answer: The case manager links clients to community resources but does not provide direct services
In the broker model, the case manager's primary role is to assess needs and connect clients to appropriate community services without direct service provision.
What is the PRIMARY purpose of documenting a client's informed consent before treatment begins?
Answer: To ensure the client understands and voluntarily agrees to treatment terms
Informed consent ensures clients voluntarily agree to treatment after understanding its nature, risks, benefits, and alternatives.
A mandated client's probation officer calls requesting a progress update. The counselor should FIRST:
Answer: Verify that a valid, signed release of information is on file
Even for court-mandated clients, a valid ROI signed by the client must be on file before disclosing any treatment information.
Which ASAM criterion dimension addresses a client's readiness to change and treatment engagement?
Answer: Dimension 4 — Readiness to Change
ASAM Dimension 4 specifically assesses the client's readiness and motivation to change substance use behavior.