CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 2 — Questions and Answers
Question 1: Under 42 CFR Part 2, which of the following actions requires written patient consent?
- Discussing a case in peer supervision within the same program
- Releasing records to a probation officer investigating a crime
- Sharing information with an outside insurance auditor (Correct answer)
- Reporting a communicable disease to public health authorities
Correct 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.
Question 2: A SOAP note's 'O' section should contain:
- The client's self-report of cravings
- The counselor's clinical interpretation of progress
- Observable, measurable data such as attendance and drug screen results (Correct answer)
- The treatment plan goals addressed in the session
Correct 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.
Question 3: Which of the following best defines 'progress notes' in addiction treatment records?
- Intake assessments completed at admission
- Session-by-session documentation of treatment activities and client response (Correct answer)
- Release of information forms signed by the client
- Quarterly statistical reports submitted to licensing boards
Correct 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.
Question 4: A court issues a subpoena for a client's substance use treatment records. Under 42 CFR Part 2, the counselor should:
- Immediately comply and release all records
- Release only the records the judge specifically names
- Refuse to release records without a court order that meets 42 CFR Part 2 criteria (Correct answer)
- Ask the client's attorney to decide within 48 hours
Correct 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.
Question 5: When documenting a client's refusal to participate in a group session, the counselor should:
- Omit the incident to avoid a negative record
- Document the refusal factually, including any reason the client provided (Correct answer)
- Discharge the client immediately and note cause
- Call the client's family before writing anything
Correct 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.
Question 6: Which element is MOST critical to include when documenting an informed consent discussion?
- The counselor's personal opinion of the treatment approach
- That the client was given information, had questions answered, and voluntarily agreed (Correct answer)
- The supervisor's countersignature before the session begins
- The client's insurance policy number
Correct 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.
Question 7: A client discloses that they drove drunk the previous night and injured no one. Which statement about confidentiality is MOST accurate?
- The counselor must report this to law enforcement under mandatory reporting laws
- This is generally protected information under 42 CFR Part 2 and does not require a report (Correct answer)
- HIPAA requires immediate disclosure to the state DMV
- The counselor must notify the client's employer
Correct 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.
CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 2
Under 42 CFR Part 2, which of the following actions requires written patient consent?