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

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?

Accepted Answer

In a medical emergency involving an imminent threat to life

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

7 years or longer depending on state law

Answer

Most states require retention of SUD records for at least 7 years, with variations based on state law and client age.

(CAT) Certified Addiction Technician Practice Test