CAS Documentation & Record Management 2

Question 1

Under 42 CFR Part 2, which of the following does NOT require patient consent before disclosing substance use disorder records?

Accepted Answer

Reporting a patient's child abuse to state authorities

Answer

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?

Accepted Answer

It uses subjective, judgmental language rather than observable behavior

Answer

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?

Accepted Answer

A description of the risks and benefits of proposed treatment

Answer

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:

Accepted Answer

Deny access unless the minor consents, if the minor applied for treatment independently

Answer

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?

Accepted Answer

To provide a comprehensive baseline for treatment planning across biological, psychological, and social domains

Answer

A biopsychosocial assessment captures the full range of factors influencing addiction and recovery to guide individualized treatment planning.

(CAS) Certified Addiction Specialist Practice Test

(CAS) Certified Addiction Specialist Practice Test

CAS Documentation & Record Management 2