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
In a group counseling session, a client discloses another group member's relapse. The counselor should:
Answer: Address confidentiality expectations within the group without naming the absent member
The counselor should reinforce group confidentiality norms and address the situation without violating the absent member's privacy.
When is it appropriate to break confidentiality WITHOUT client consent in substance use counseling?
Answer: When the counselor suspects child abuse or neglect
Mandated reporting laws require counselors to break confidentiality when they suspect child abuse or neglect, regardless of client consent.
Which documentation element BEST demonstrates medical necessity for continued substance use treatment?
Answer: Evidence that the client still meets clinical criteria justifying the current level of care
Medical necessity documentation must show the client continues to meet clinical criteria that justify the level of care being provided.
A counselor uses the DAP note format. What does the 'A' section document?
Answer: The counselor's assessment and clinical interpretation of the data
In DAP notes, 'A' stands for Assessment, where the counselor records clinical interpretation and progress toward goals.
A client requests a copy of their own treatment records. Under HIPAA, the counselor should:
Answer: Provide access within 30 days unless a specific legal exception applies
HIPAA grants clients the right to access their own health records within 30 days, with limited exceptions such as psychotherapy notes.
In case management, 'level of care determination' refers to:
Answer: Matching the client's clinical needs to the appropriate intensity of treatment services
Level of care determination matches the client's assessed clinical needs to the appropriate treatment intensity using criteria such as ASAM.
Which of the following is a key feature that distinguishes psychotherapy notes from standard progress notes under HIPAA?
Answer: Psychotherapy notes receive additional protection and require separate authorization for release
Under HIPAA, psychotherapy notes are kept separate from the general record and require specific client authorization for most disclosures.