CAT Documentation and Record Keeping Flashcards
6 cards from real CAT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CAT Documentation and Record Keeping flashcards as text
Which of the following best describes a treatment plan in addiction technician practice?
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.
What does the acronym SOAP stand for in clinical documentation?
Answer: Subjective, Objective, Assessment, Plan
SOAP notes organize documentation into Subjective (client's report), Objective (observed data), Assessment, and Plan.
Which practice best protects client confidentiality when using electronic health records (EHR)?
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.
A client requests a copy of their own treatment records. Under HIPAA, what is the facility generally required to do?
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.
Which term refers to the official record that shows who has accessed or received a client's treatment information?
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.
When documenting a group session, which approach best protects individual client confidentiality?
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.