CAS Documentation & Record Management 5

Question 1

A subpoena is issued for a client's SUD treatment records. Under 42 CFR Part 2, the counselor should:

Accepted Answer

Consult legal counsel and not release records unless accompanied by a court order meeting 42 CFR Part 2 requirements or client consent

Answer

A subpoena alone is insufficient to release SUD records under 42 CFR Part 2; a court order that meets specific criteria or patient consent is required.

Question 2

Which of the following BEST reflects the DAP progress note format?

Accepted Answer

Data, Assessment, Plan

Answer

DAP stands for Data (objective and subjective observations), Assessment (clinical interpretation), and Plan (next steps), a common SUD counseling note format.

Question 3

A client's record includes a note written by a previous counselor that the current counselor believes is inaccurate. The current counselor should:

Accepted Answer

Add an addendum to the record noting the disagreement without altering the original entry

Answer

Prior entries must not be altered; the appropriate response is to add a dated addendum documenting the clinician's clinical disagreement or correction.

Question 4

Which of the following is the MOST appropriate timeframe standard for completing a progress note after a counseling session?

Accepted Answer

Within 24 hours or per the agency's documented policy

Answer

Best practice and most regulatory standards require progress notes to be completed within 24 hours of the session or according to the agency's established policy.

Question 5

A counselor's agency begins transitioning from paper to electronic records. Which is the MOST important security measure to implement first for electronic SUD records?

Accepted Answer

Implementing role-based access controls so only authorized staff can view records

Answer

Role-based access controls restrict EHR access to authorized personnel only, protecting patient confidentiality as required by HIPAA and 42 CFR Part 2.

(CAS) Certified Addiction Specialist Practice Test

(CAS) Certified Addiction Specialist Practice Test

CAS Documentation & Record Management 5