CAT CAT Documentation and Record Keeping

Question 1

Which federal regulation governs the confidentiality of substance use disorder patient records in the US?

Accepted Answer

42 CFR Part 2

Answer

HIPAA Privacy Rule only

Answer

Title VII of the Civil Rights Act

Answer

The Controlled Substances Act

Question 2

A client's treatment record may be disclosed without written consent in which of the following situations?

Accepted Answer

In a medical emergency involving an imminent threat to life

Answer

To a potential employer requesting information

Answer

To law enforcement conducting a routine investigation

Answer

To a family member who claims concern for the client

Question 3

What is the primary purpose of progress notes in a client's addiction treatment record?

Accepted Answer

To document the client's response to treatment and any changes in condition

Answer

To satisfy billing requirements only

Answer

To record staff complaints about difficult clients

Answer

To replace the original treatment plan

Question 4

Which element is MOST important to include when documenting a client's refusal of a recommended service?

Accepted Answer

The client's statement and the information provided to them about risks

Answer

The technician's personal opinion about the refusal

Answer

The names of other clients who accepted the service

Answer

A request for supervisor punishment of the client

Question 5

How long must substance use disorder treatment records typically be retained under most US state regulations?

Accepted Answer

7 years or longer depending on state law

Answer

1 year

Answer

3 years

Answer

Indefinitely

Question 6

When a client signs a release of information, what must the form include to be valid under 42 CFR Part 2?

Accepted Answer

The name of the person or agency to receive the information and the purpose of disclosure

Answer

Only the client's signature

Answer

The signature of the facility director

Answer

A notarized statement from a judge