CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 3 — Questions and Answers
Question 1: The 'minimum necessary' standard under HIPAA requires counselors to:
- Share the full clinical file whenever any request is made
- Disclose only the information needed to accomplish the intended purpose (Correct answer)
- Withhold all records unless the client is present during disclosure
- Obtain supervisor approval for every disclosure regardless of scope
Correct answer: Disclose only the information needed to accomplish the intended purpose
HIPAA's minimum necessary standard limits disclosures to the least amount of protected health information needed to fulfill the purpose of the request.
Question 2: Which of the following is an example of a 'covered entity' under HIPAA?
- A client's employer who pays for treatment
- A substance abuse treatment program that transmits health information electronically (Correct answer)
- A law enforcement agency investigating drug crimes
- A peer support specialist working independently without a billing system
Correct answer: A substance abuse treatment program that transmits health information electronically
A substance abuse treatment program that electronically transmits health information for billing is a covered entity subject to HIPAA regulations.
Question 3: A treatment record amendment request from a client should be:
- Always honored by physically altering the original note
- Acknowledged and responded to, with the client's request added to the record if denied (Correct answer)
- Ignored if the counselor believes the record is accurate
- Forwarded directly to the state licensing board
Correct answer: Acknowledged and responded to, with the client's request added to the record if denied
Under HIPAA, clients have the right to request amendments; if denied, the denial must be documented and the client's disagreement noted in the record.
Question 4: Which of the following BEST describes a Confidential Communication Request (CCR) under 42 CFR Part 2?
- A court order compelling testimony from a substance abuse counselor
- A client's request that communications be sent to an alternate address or by alternate means (Correct answer)
- A written agreement between two agencies to share data
- A HIPAA authorization form for insurance billing
Correct answer: A client's request that communications be sent to an alternate address or by alternate means
A Confidential Communication Request allows clients to ask that sensitive communications be directed to a location or method that protects their privacy.
Question 5: Documentation errors in a clinical record should be corrected by:
- Using correction fluid (white-out) to cover the mistake
- Drawing a single line through the error, initialing, dating, and writing the correct entry (Correct answer)
- Destroying the original note and rewriting it
- Leaving the error and writing 'ignore' next to it
Correct answer: Drawing a single line through the error, initialing, dating, and writing the correct entry
Proper error correction requires a single strikethrough so the original entry remains legible, followed by initials, date, and the correct information.
Question 6: Under 42 CFR Part 2, which of the following is permitted WITHOUT patient consent?
- Sharing records with a client's spouse who is paying for treatment
- Reporting suspected child abuse to child protective services as required by state law (Correct answer)
- Providing records to an employer who refers clients to the program
- Releasing information to a co-occurring mental health provider at another agency
Correct answer: Reporting suspected child abuse to child protective services as required by state law
42 CFR Part 2 contains an exception allowing mandated reporters to report child abuse or neglect without patient consent when state law requires it.
Question 7: A client's treatment plan should be reviewed and updated at minimum:
- Only when the client requests a change
- According to program policy, regulatory requirements, and whenever significant changes occur (Correct answer)
- Once per year regardless of clinical changes
- Only at program discharge
Correct answer: According to program policy, regulatory requirements, and whenever significant changes occur
Treatment plans must be reviewed regularly per program policy and regulatory standards, and updated whenever there is a significant change in the client's status or goals.
CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 3
The 'minimum necessary' standard under HIPAA requires counselors to: