CADC Documentation and Case Management 3

Question 1

Under 42 CFR Part 2, substance use disorder treatment records receive special protection because:

Accepted Answer

Disclosure could harm patients by deterring them from seeking treatment

Answer

They are owned by the insurance company paying for treatment

Answer

They are classified as mental health records under federal law

Answer

They require annual renewal of consent by the client

Question 2

When documenting a client's discharge summary, which information is MOST important to include for continuity of care?

Accepted Answer

Goals achieved, unresolved issues, and aftercare recommendations

Answer

The client's billing history and copayment amounts

Answer

A list of all staff members who provided services

Answer

The counselor's personal observations about the client's motivation

Question 3

A counselor discovers a documentation error in a client's chart from a previous session. The CORRECT way to correct it is to:

Accepted Answer

Draw a single line through the error, write the correction, and initial and date it

Answer

Use white-out to cover the error and write the correct information

Answer

Remove the page and rewrite the entire note

Answer

Leave the error unchanged and add a separate correction note

Question 4

Which of the following BEST reflects the broker model of case management?

Accepted Answer

The case manager links clients to community resources but does not provide direct services

Answer

The case manager provides all therapeutic services directly to the client

Answer

The case manager focuses exclusively on the client's strengths and assets

Answer

The case manager acts as both therapist and medication prescriber

Question 5

What is the PRIMARY purpose of documenting a client's informed consent before treatment begins?

Accepted Answer

To ensure the client understands and voluntarily agrees to treatment terms

Answer

To protect the agency from liability in malpractice lawsuits

Answer

To satisfy accreditation body requirements for the facility

Answer

To establish the client's financial responsibility for services

Question 6

A mandated client's probation officer calls requesting a progress update. The counselor should FIRST:

Accepted Answer

Verify that a valid, signed release of information is on file

Answer

Provide a verbal update since the referral came from the court

Answer

Fax a full treatment summary to comply with legal requirements

Answer

Refuse all communication with third parties to protect confidentiality

Question 7

Which ASAM criterion dimension addresses a client's readiness to change and treatment engagement?

Accepted Answer

Dimension 4 — Readiness to Change

Answer

Dimension 1 — Acute Intoxication and Withdrawal Potential

Answer

Dimension 5 — Relapse, Continued Use, or Continued Problem Potential

Answer

Dimension 6 — Recovery/Living Environment