CASAC Clinical Documentation and Reporting 5 — Questions and Answers
Question 1: A client in a methadone maintenance program is also being treated for depression by a psychiatrist. To share records between providers, the counselor needs:
- A verbal agreement from the client
- A written release of information signed by the client that meets 42 CFR Part 2 requirements (Correct answer)
- Approval from the program director only
- A court order in all circumstances
Correct 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.
Question 2: Which of the following is an example of a measurable, well-written treatment plan goal?
- Client will feel better about themselves
- Client will understand the dangers of drinking
- Client will attend 3 AA meetings per week and maintain sobriety as verified by weekly urinalysis for 90 days (Correct answer)
- Client will work on their issues with family
Correct 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.
Question 3: When a client presents with a co-occurring disorder, documentation of the treatment plan should:
- Address only the substance use disorder until it is fully stabilized
- Separately address the mental health disorder in a different chart
- Integrate goals addressing both the substance use and mental health conditions (Correct answer)
- Defer mental health documentation to the psychiatrist exclusively
Correct 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.
Question 4: A counselor's progress note should be completed:
- At the end of each week summarizing all sessions
- As soon as possible after the session while details are accurate (Correct answer)
- Only when significant events occur during treatment
- Within 30 days of the session per standard practice
Correct 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.
Question 5: Which of the following must be included in a discharge summary for a client leaving residential substance abuse treatment?
- A prognosis based solely on the counselor's intuition
- Summary of treatment provided, progress toward goals, aftercare plan, and reason for discharge (Correct answer)
- Only the client's demographics and dates of service
- A list of all staff who interacted with the client
Correct 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.
Question 6: Under 42 CFR Part 2, which of the following disclosures is permitted WITHOUT client consent?
- Sharing records with the client's employer
- Reporting to law enforcement upon request
- Disclosure in a medical emergency involving immediate threat to life (Correct answer)
- Providing records to an insurance company for billing
Correct 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.
Question 7: A counselor is completing a Level of Care assessment using ASAM criteria. Which of the following dimensions addresses the client's readiness to change?
- Dimension 1: Acute Intoxication and Withdrawal Potential
- Dimension 3: Emotional, Behavioral, or Cognitive Conditions
- Dimension 4: Readiness to Change (Correct answer)
- Dimension 6: Recovery Environment
Correct 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.
CASAC Clinical Documentation and Reporting 5
A client in a methadone maintenance program is also being treated for depression by a psychiatrist.
To share records between providers, the counselor needs: