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
Which of the following BEST describes the purpose of a clinical supervision note in a counselor's file?
Answer: To record case discussions, recommendations, and supervisee development issues
Supervision notes document case consultation, skill development feedback, and recommendations to support the counselor's professional growth.
A client's treatment plan objective states: 'Client will attend 3 AA meetings per week for 30 days.' This objective is best described as:
Answer: Specific and measurable with a clear timeframe
This objective is specific (3 meetings/week), measurable (attendance), and time-bound (30 days), meeting criteria for a well-written behavioral goal.
In strengths-based case management, the counselor's PRIMARY focus is on:
Answer: Identifying and mobilizing the client's existing resources and capabilities
Strengths-based case management emphasizes identifying and building on the client's existing strengths, skills, and community resources.
An ethical violation occurs when a counselor documents a session that never took place in order to meet billing requirements. This act is known as:
Answer: Fraudulent documentation or billing fraud
Documenting services that were not provided constitutes fraudulent documentation and billing fraud, which is both an ethical and criminal violation.
When coordinating a client's care with a medical provider, the counselor must ensure that any communication:
Answer: Is covered by a valid, signed release of information specific to that provider
Any release of SUD treatment information to a medical provider requires a valid, signed ROI that specifies that provider.
Which of the following scenarios MOST clearly represents a boundary violation in documentation practices?
Answer: A counselor includes personal opinions about the client's lifestyle in the clinical record
Including personal opinions or judgments about a client's lifestyle in clinical documentation is unprofessional and constitutes a documentation boundary violation.
A counselor is transitioning a client from residential to outpatient level of care. Which document is MOST essential to prepare for this transition?
Answer: A comprehensive discharge summary with aftercare plan and referrals
A comprehensive discharge summary with an aftercare plan and referrals ensures continuity of care and communicates the client's needs to the next treatment provider.