CAS Documentation & Record Management 3 ā Questions and Answers
Question 1: A client signs a release of information allowing the counselor to speak with their probation officer. The client later verbally revokes this consent. The counselor should:
- Continue sharing information until a written revocation is received
- Honor the revocation immediately for future disclosures while documenting it in the record (Correct answer)
- Notify the probation officer that the client revoked consent
- Seek a court order to determine whether to continue disclosures
Correct answer: Honor the revocation immediately for future disclosures while documenting it in the record
Consent can be revoked at any time, and the counselor must stop future disclosures and document the revocation, though prior disclosures made in good faith remain valid.
Question 2: When documenting a client's relapse in a progress note, the CAS counselor should FIRST:
- Notify the client's family immediately
- Record the facts objectively, including substances used, amount, and context (Correct answer)
- Discharge the client from the program for non-compliance
- Remove previous progress notes that indicated progress
Correct answer: Record the facts objectively, including substances used, amount, and context
Objective, factual documentation of a relapseāsubstance, quantity, circumstancesāprovides the clinical basis for adjusting the treatment plan.
Question 3: HIPAA's minimum necessary standard requires that disclosures of protected health information should:
- Include the complete medical record to avoid missing relevant details
- Be limited to the least amount of information needed to accomplish the intended purpose (Correct answer)
- Be approved by the state licensing board before release
- Match whatever the requesting party asks for
Correct answer: Be limited to the least amount of information needed to accomplish the intended purpose
The minimum necessary standard mandates that only the PHI required for the specific purpose be shared, protecting patient privacy.
Question 4: Which situation would MOST likely require a mandatory report that overrides 42 CFR Part 2 confidentiality protections?
- A client discloses past marijuana use in another state
- A client states they plan to physically harm an identified third party (Correct answer)
- A client admits to missing a court-ordered appointment
- A client describes drinking alcohol at home
Correct answer: A client states they plan to physically harm an identified third party
Duty-to-warn obligations triggered by a credible, specific threat to an identified third party can override SUD confidentiality protections.
Question 5: A signed consent form for release of SUD records is valid under 42 CFR Part 2 only if it includes:
- The client's Social Security number and date of birth
- The name of the person or organization authorized to receive the information (Correct answer)
- The signature of the treating physician
- The client's insurance carrier information
Correct answer: The name of the person or organization authorized to receive the information
42 CFR Part 2 requires that a valid consent identify the specific person or entity authorized to receive the disclosed information.
Question 6: A CAS counselor discovers an error in a previously signed progress note. The CORRECT way to correct this error is to:
- Use white-out to cover the mistake and write the correction over it
- Draw a single line through the error, initial it, date it, and write the correction (Correct answer)
- Rewrite the entire note from scratch with the correct information
- Leave the error unchanged to preserve the original record
Correct answer: Draw a single line through the error, initial it, date it, and write the correction
Proper error correction in clinical records involves a single strikethrough, initials, and dateāpreserving the original entry while noting the correction.
Question 7: Which statement BEST describes the relationship between a treatment plan and progress notes?
- Progress notes are used to replace the treatment plan once treatment begins
- Progress notes document the client's response to interventions identified in the treatment plan (Correct answer)
- Treatment plans are only updated when a client is discharged
- Progress notes and treatment plans are maintained in separate, unrelated records
Correct answer: Progress notes document the client's response to interventions identified in the treatment plan
Progress notes should consistently reference and reflect movement toward or away from the goals and interventions established in the treatment plan.
CAS Documentation & Record Management 3
A client signs a release of information allowing the counselor to speak with their probation officer.
The client later verbally revokes this consent.
The counselor should: