Clinical Documentation and Reporting Flashcards
7 cards from real CASAC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Clinical Documentation and Reporting flashcards as text
A client in a methadone maintenance program is also being treated for depression by a psychiatrist. To share records between providers, the counselor needs:
Answer: A written release of information signed by the client that meets 42 CFR Part 2 requirements
42 CFR Part 2 requires a written client consent form with specific elements before substance use disorder treatment information can be shared, even with other treating providers.
Which of the following is an example of a measurable, well-written treatment plan goal?
Answer: Client will attend 3 AA meetings per week and maintain sobriety as verified by weekly urinalysis for 90 days
A measurable goal specifies observable behaviors, frequency, verification method, and timeframe, making progress objectively trackable.
When a client presents with a co-occurring disorder, documentation of the treatment plan should:
Answer: Integrate goals addressing both the substance use and mental health conditions
Best practice for co-occurring disorders requires integrated treatment planning that addresses both conditions simultaneously within the same treatment plan.
A counselor's progress note should be completed:
Answer: As soon as possible after the session while details are accurate
Progress notes should be completed as soon as possible after each session to ensure accuracy and completeness while the clinical details are fresh.
Which of the following must be included in a discharge summary for a client leaving residential substance abuse treatment?
Answer: Summary of treatment provided, progress toward goals, aftercare plan, and reason for discharge
A discharge summary must comprehensively document treatment provided, goal progress, discharge reason, and aftercare recommendations to ensure continuity of care.
Under 42 CFR Part 2, which of the following disclosures is permitted WITHOUT client consent?
Answer: Disclosure in a medical emergency involving immediate threat to life
42 CFR Part 2 permits disclosure without consent in a bona fide medical emergency where the client's life is in immediate danger.
A counselor is completing a Level of Care assessment using ASAM criteria. Which of the following dimensions addresses the client's readiness to change?
Answer: Dimension 4: Readiness to Change
ASAM Dimension 4 specifically assesses the client's readiness and interest in changing substance use behavior, guiding motivational aspects of treatment planning.