CAS Documentation & Record Management 4

Question 1

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

Accepted Answer

A client's name linked to their SUD diagnosis in any format

Answer

PHI is any individually identifiable health information, including a client's name combined with a health condition, regardless of the medium.

Question 2

A new client refuses to sign a release of information to allow communication with their prescribing physician. The counselor should:

Accepted Answer

Document the refusal and proceed with treatment while respecting the client's autonomy

Answer

Clients have the right to refuse releases; the counselor should document the refusal and continue treatment, while discussing potential clinical implications.

Question 3

Which of the following elements is MOST essential in a discharge summary for a client completing residential SUD treatment?

Accepted Answer

A summary of treatment provided, progress toward goals, and aftercare plan

Answer

A discharge summary must capture the treatment course, goal attainment, and a concrete aftercare plan to support continuity of care.

Question 4

Which federal regulation specifically governs the confidentiality of substance use disorder patient records in federally assisted programs?

Accepted Answer

42 CFR Part 2 (Confidentiality of Substance Use Disorder Patient Records)

Answer

42 CFR Part 2 provides SUD-specific confidentiality protections that are stricter than HIPAA for federally assisted programs.

Question 5

A counselor is documenting a group therapy session. Which approach best protects the confidentiality of all group members?

Accepted Answer

Write a general note describing group themes and the identified client's participation without naming other members

Answer

Group session notes should describe the client's participation and group themes without identifying or quoting other members to protect their confidentiality.

(CAS) Certified Addiction Specialist Practice Test

(CAS) Certified Addiction Specialist Practice Test

CAS Documentation & Record Management 4