Practice Test Geeks(CADC) Certification Prep and Alcohol and Drug Counselor Practice Test
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Alcohol and Drug Counselor Clinical Documentation and Confidentiality Flashcards

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  1. Under 42 CFR Part 2, which of the following actions requires written patient consent?

    Answer: Sharing information with an outside insurance auditor

    42 CFR Part 2 requires written patient consent before disclosing records to outside entities such as insurance auditors, unless a specific exception applies.

  2. A SOAP note's 'O' section should contain:

    Answer: Observable, measurable data such as attendance and drug screen results

    The Objective section of a SOAP note documents observable, factual, and measurable data that does not rely on the client's self-report.

  3. Which of the following best defines 'progress notes' in addiction treatment records?

    Answer: Session-by-session documentation of treatment activities and client response

    Progress notes document each clinical contact, recording treatment activities, client responses, and movement toward treatment plan goals.

  4. A court issues a subpoena for a client's substance use treatment records. Under 42 CFR Part 2, the counselor should:

    Answer: Refuse to release records without a court order that meets 42 CFR Part 2 criteria

    A standard subpoena does not override 42 CFR Part 2; a qualifying court order with specific findings is required before records can be released.

  5. When documenting a client's refusal to participate in a group session, the counselor should:

    Answer: Document the refusal factually, including any reason the client provided

    Objective, factual documentation of clinical events — including refusals — is required to maintain an accurate and legally defensible record.

  6. Which element is MOST critical to include when documenting an informed consent discussion?

    Answer: That the client was given information, had questions answered, and voluntarily agreed

    Valid informed consent documentation must show the client received information, understood it, had the opportunity to ask questions, and agreed voluntarily.

  7. A client discloses that they drove drunk the previous night and injured no one. Which statement about confidentiality is MOST accurate?

    Answer: This is generally protected information under 42 CFR Part 2 and does not require a report

    Past criminal behavior that poses no identified imminent danger to a specific person is typically protected under 42 CFR Part 2 and does not trigger mandatory reporting.