CAT CAT Documentation and Record Keeping 2

Question 1

Which of the following best describes a treatment plan in addiction technician practice?

Accepted Answer

A collaborative, individualized document outlining goals, objectives, and services

Answer

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?

Accepted Answer

Subjective, Objective, Assessment, Plan

Answer

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)?

Accepted Answer

Logging out of EHR systems when not in use and using strong passwords

Answer

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?

Accepted Answer

Provide the records within 30 days of the request

Answer

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?

Accepted Answer

Audit trail or disclosure log

Answer

An audit trail or disclosure log tracks every instance of access or release of a client's protected health information.

(CAT) Certified Addiction Technician Practice Test