CAT CAT Documentation and Record Keeping 2 — Questions and Answers
Question 1: Which of the following best describes a treatment plan in addiction technician practice?
- A list of rules the client must follow or be discharged
- A collaborative, individualized document outlining goals, objectives, and services (Correct answer)
- A billing summary for insurance purposes
- A document completed solely by the clinical supervisor
Correct answer: A collaborative, individualized document outlining goals, objectives, and services
A treatment plan is a collaborative, individualized document that guides care based on the client's needs and goals.
Question 2: What does the acronym SOAP stand for in clinical documentation?
- Subjective, Objective, Assessment, Plan (Correct answer)
- Symptoms, Observations, Actions, Progress
- Screening, Outreach, Assistance, Program
- Subject, Outcome, Approach, Protocol
Correct answer: Subjective, Objective, Assessment, Plan
SOAP notes organize documentation into Subjective (client's report), Objective (observed data), Assessment, and Plan.
Question 3: Which practice best protects client confidentiality when using electronic health records (EHR)?
- Sharing login credentials with trusted coworkers for efficiency
- Logging out of EHR systems when not in use and using strong passwords (Correct answer)
- Printing all records and keeping them in an unlocked drawer
- Discussing client information in the hallway to save time
Correct answer: Logging out of EHR systems when not in use and using strong passwords
Logging out and using strong passwords are basic but critical safeguards for maintaining EHR confidentiality.
Question 4: A client requests a copy of their own treatment records. Under HIPAA, what is the facility generally required to do?
- Deny the request to protect the client from distressing information
- Provide the records within 30 days of the request (Correct answer)
- Charge the client a fee equal to the cost of the entire program
- Require a court order before releasing records to the client
Correct answer: Provide the records within 30 days of the request
HIPAA grants clients the right to access their own health records, typically within 30 days of the request.
Question 5: Which term refers to the official record that shows who has accessed or received a client's treatment information?
- Incident log
- Audit trail or disclosure log (Correct answer)
- Intake form
- Continuing care plan
Correct answer: Audit trail or disclosure log
An audit trail or disclosure log tracks every instance of access or release of a client's protected health information.
Question 6: When documenting a group session, which approach best protects individual client confidentiality?
- Recording verbatim statements from all group members by name
- Documenting the group theme and each client's participation without quoting others (Correct answer)
- Skipping documentation of group sessions entirely
- Listing all group members' diagnoses in each individual's chart
Correct answer: Documenting the group theme and each client's participation without quoting others
Group session notes should focus on the individual client's participation and the session theme without disclosing other members' statements.
CAT CAT Documentation and Record Keeping 2
Which of the following best describes a treatment plan in addiction technician practice?