CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 2

Question 1

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

Accepted Answer

Sharing information with an outside insurance auditor

Answer

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:

Accepted Answer

Observable, measurable data such as attendance and drug screen results

Answer

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?

Accepted Answer

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

Answer

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:

Accepted Answer

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

Answer

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:

Accepted Answer

Document the refusal factually, including any reason the client provided

Answer

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

Alcohol and Drug Counselor Exam Practice Test

Alcohol and Drug Counselor Exam Practice Test

CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 2