Alcohol and Drug Counselor Clinical Documentation and Confidentiality 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 Alcohol and Drug Counselor Clinical Documentation and Confidentiality flashcards as text
Which scenario represents a proper use of 'qualified service organization agreements' (QSOAs) under 42 CFR Part 2?
Answer: A program shares records with a billing company that signs a QSOA agreeing to be bound by 42 CFR Part 2
A QSOA allows a program to share necessary information with service organizations (such as billing companies) when the organization agrees in writing to comply with 42 CFR Part 2.
A counselor is required to maintain records for a minimum period after discharge. This period is primarily governed by:
Answer: State law and program policy, which may vary by jurisdiction
Record retention requirements are set by state law, accreditation standards, and program policy, and may differ significantly from state to state.
Which of the following BEST describes 'DAP' format in progress notes?
Answer: Data, Assessment, Plan
DAP notes are structured as Data (objective and subjective information), Assessment (clinical interpretation), and Plan (next steps in treatment).
When a client signs a release of information authorizing disclosure to their primary care physician, the authorization is generally valid for:
Answer: The time period specified on the authorization form
A valid authorization must include an expiration date or event, and disclosures are permitted only within the scope and time period specified.
A client verbally revokes their consent for a release of information. The counselor should:
Answer: Honor the revocation immediately and document it in writing
Clients may revoke consent at any time; the counselor must stop disclosures immediately and document the revocation in the record.
Which of the following is an example of a breach of confidentiality NOT covered by a recognized exception?
Answer: Disclosing a client's treatment status to their landlord at the landlord's request
Sharing a client's treatment information with their landlord does not fall under any recognized exception and constitutes an unauthorized disclosure.
Electronic health records (EHR) used in substance abuse treatment must comply with 42 CFR Part 2 by:
Answer: Implementing access controls and audit trails to prevent unauthorized disclosure
EHR systems holding 42 CFR Part 2 data must have role-based access controls and audit trails to ensure only authorized disclosures occur.