CADC Documentation and Case Management 2

Question 1

Under HIPAA, which of the following is considered Protected Health Information (PHI)?

Accepted Answer

A client's name combined with their treatment dates

Answer

A client's general diagnosis shared in a staff meeting without identifiers

Answer

Aggregate statistical data about the counseling program

Answer

Anonymous survey results about client satisfaction

Question 2

Which element is MOST critical to include in a treatment plan to ensure it is measurable?

Accepted Answer

Specific, observable behavioral goals with target dates

Answer

A broad statement of the client's presenting problem

Answer

The counselor's clinical impressions of the client

Answer

A description of the client's family history

Question 3

When a client discloses they plan to harm a specific, identifiable third party, the counselor's duty to warn typically requires:

Accepted Answer

Notifying law enforcement and/or the intended victim

Answer

Documenting the threat in the chart without further action

Answer

Waiting until the next session to reassess the threat

Answer

Consulting a supervisor before taking any action

Question 4

Which type of case management model positions the counselor as a direct provider who personally delivers most services to the client?

Accepted Answer

Clinical case management model

Answer

Broker model

Answer

Strengths-based model

Answer

Community support model

Question 5

In the SOAP note format, subjective information refers to:

Accepted Answer

What the client reports about their own experience

Answer

The counselor's clinical assessment and diagnosis

Answer

Objective test results and observable behaviors

Answer

The plan for future treatment interventions

Question 6

A release of information (ROI) form is INVALID if it is missing which of the following components?

Accepted Answer

The specific purpose or need for the disclosure

Answer

The counselor's professional license number

Answer

The client's insurance policy number

Answer

The name of the referring physician

Question 7

Which of the following BEST describes the purpose of a biopsychosocial assessment in substance use counseling documentation?

Accepted Answer

To provide a comprehensive foundation for individualized treatment planning

Answer

To determine the client's insurance reimbursement eligibility

Answer

To satisfy court requirements for mandated clients only

Answer

To document the counselor's qualifications for treating the client