CAS Documentation & Record Management 2 — Questions and Answers
Question 1: Under 42 CFR Part 2, which of the following does NOT require patient consent before disclosing substance use disorder records?
- Sharing records with a managed care organization for billing
- Reporting a patient's child abuse to state authorities (Correct answer)
- Transferring records to another SUD treatment provider
- Notifying an employer of a patient's diagnosis
Correct answer: Reporting a patient's child abuse to state authorities
42 CFR Part 2 contains an exception that permits disclosure without consent when mandatory child abuse reporting laws require it.
Question 2: A counselor writes a progress note that reads: 'Client appeared unmotivated and resistant today.' What is the primary problem with this documentation?
- It is too brief to be clinically useful
- It uses subjective, judgmental language rather than observable behavior (Correct answer)
- It does not include the date and time
- It lacks a treatment plan reference
Correct answer: It uses subjective, judgmental language rather than observable behavior
Progress notes should describe observable behaviors rather than subjective interpretations like 'unmotivated,' which are clinician judgments, not facts.
Question 3: Which element is REQUIRED in a legally defensible informed consent document for SUD treatment?
- A list of all staff credentials
- The facility's accreditation number
- A description of the risks and benefits of proposed treatment (Correct answer)
- The client's insurance policy number
Correct answer: A description of the risks and benefits of proposed treatment
Informed consent must include risks, benefits, and alternatives of treatment so the client can make a voluntary, informed decision.
Question 4: A patient's legal guardian requests to inspect the minor's SUD treatment records. Under 42 CFR Part 2, the counselor should:
- Provide immediate access since the guardian has legal authority
- Deny access unless the minor consents, if the minor applied for treatment independently (Correct answer)
- Forward the request to the billing department
- Require a court order before releasing any records
Correct answer: Deny access unless the minor consents, if the minor applied for treatment independently
42 CFR Part 2 protects minors who independently seek SUD treatment; a guardian's authority may not override that confidentiality without the minor's consent.
Question 5: Which of the following best describes the purpose of a biopsychosocial assessment in clinical documentation?
- To satisfy insurance billing requirements only
- To provide a comprehensive baseline for treatment planning across biological, psychological, and social domains (Correct answer)
- To document the client's criminal history for legal purposes
- To establish the counselor's credentials for the record
Correct answer: To provide a comprehensive baseline for treatment planning across biological, psychological, and social domains
A biopsychosocial assessment captures the full range of factors influencing addiction and recovery to guide individualized treatment planning.
Question 6: An audit reveals that a counselor routinely back-dates progress notes to match the date of service. This practice is BEST described as:
- Acceptable if done within the same billing cycle
- Fraudulent documentation that violates ethical and legal standards (Correct answer)
- Permissible as long as the supervisor approves
- A minor clerical issue requiring retraining only
Correct answer: Fraudulent documentation that violates ethical and legal standards
Back-dating records constitutes falsification of medical documents, which is both unethical and potentially criminal under healthcare fraud statutes.
Question 7: Which type of progress note format requires the counselor to document Subjective data, Objective data, Assessment, and Plan?
- DAP
- BIRP
- SOAP (Correct answer)
- PIE
Correct answer: SOAP
SOAP stands for Subjective, Objective, Assessment, and Plan, and is a widely used structured format in healthcare documentation.
CAS Documentation & Record Management 2
Under 42 CFR Part 2, which of the following does NOT require patient consent before disclosing substance use disorder records?