CASAC Clinical Documentation and Reporting 5

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:

Accepted Answer

A written release of information signed by the client that meets 42 CFR Part 2 requirements

Answer

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?

Accepted Answer

Client will attend 3 AA meetings per week and maintain sobriety as verified by weekly urinalysis for 90 days

Answer

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:

Accepted Answer

Integrate goals addressing both the substance use and mental health conditions

Answer

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:

Accepted Answer

As soon as possible after the session while details are accurate

Answer

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?

Accepted Answer

Summary of treatment provided, progress toward goals, aftercare plan, and reason for discharge

Answer

A discharge summary must comprehensively document treatment provided, goal progress, discharge reason, and aftercare recommendations to ensure continuity of care.

CASAC - Credentialed Alcoholism and Substance Abuse Counselor Practice Test

CASAC - Credentialed Alcoholism and Substance Abuse Counselor Practice Test

CASAC Clinical Documentation and Reporting 5