CAT CAT Documentation and Record Keeping 1 — Questions and Answers
Question 1: Which federal regulation governs the confidentiality of substance use disorder patient records in the US?
- 42 CFR Part 2 (Correct answer)
- HIPAA Privacy Rule only
- Title VII of the Civil Rights Act
- The Controlled Substances Act
Correct answer: 42 CFR Part 2
42 CFR Part 2 provides stricter confidentiality protections for substance use disorder records than HIPAA.
Question 2: A client's treatment record may be disclosed without written consent in which of the following situations?
- To a potential employer requesting information
- In a medical emergency involving an imminent threat to life (Correct answer)
- To law enforcement conducting a routine investigation
- To a family member who claims concern for the client
Correct answer: In a medical emergency involving an imminent threat to life
Under 42 CFR Part 2, disclosure without consent is permitted when there is a bona fide medical emergency.
Question 3: What is the primary purpose of progress notes in a client's addiction treatment record?
- To satisfy billing requirements only
- To document the client's response to treatment and any changes in condition (Correct answer)
- To record staff complaints about difficult clients
- To replace the original treatment plan
Correct answer: To document the client's response to treatment and any changes in condition
Progress notes track ongoing treatment response, goal progress, and any changes that affect care.
Question 4: Which element is MOST important to include when documenting a client's refusal of a recommended service?
- The technician's personal opinion about the refusal
- The client's statement and the information provided to them about risks (Correct answer)
- The names of other clients who accepted the service
- A request for supervisor punishment of the client
Correct answer: The client's statement and the information provided to them about risks
Documenting the client's statement and education provided protects both the client's autonomy and the technician's legal standing.
Question 5: How long must substance use disorder treatment records typically be retained under most US state regulations?
- 1 year
- 3 years
- 7 years or longer depending on state law (Correct answer)
- Indefinitely
Correct answer: 7 years or longer depending on state law
Most states require retention of SUD records for at least 7 years, with variations based on state law and client age.
Question 6: When a client signs a release of information, what must the form include to be valid under 42 CFR Part 2?
- The name of the person or agency to receive the information and the purpose of disclosure (Correct answer)
- Only the client's signature
- The signature of the facility director
- A notarized statement from a judge
Correct answer: The name of the person or agency to receive the information and the purpose of disclosure
A valid 42 CFR Part 2 consent form must specify the recipient, purpose, and scope of the disclosed information.
CAT CAT Documentation and Record Keeping 1
Which federal regulation governs the confidentiality of substance use disorder patient records in the US?