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
What is a 'minimum necessary' standard as it relates to SUD record disclosure?
Answer: Only releasing the least amount of information needed to accomplish the stated purpose
The minimum necessary standard requires that only the information needed for a specific purpose be shared, limiting unnecessary disclosure.
Which of the following is an example of a breach of client confidentiality?
Answer: Telling a friend at a social gathering that a specific person is in your program
Disclosing a client's participation in a treatment program to unauthorized individuals violates 42 CFR Part 2 and HIPAA.
When must a client's treatment plan be reviewed and updated according to best practices?
Answer: At regular intervals or when significant changes in the client's condition occur
Treatment plans should be reviewed regularly and updated whenever the client's condition, goals, or circumstances change significantly.
Which information is typically included in an intake or admission record for a new SUD client?
Answer: Identifying information, presenting problem, medical and substance use history, and consent forms
Intake records capture essential demographics, presenting concerns, history, and consent documentation needed to begin services.
What action should an addiction technician take if they discover an error in a client's paper record?
Answer: Draw a single line through the error, write the correction, initial, and date it
Correct documentation errors by drawing a single line through the mistake, then initialing and dating the correction to maintain a clear audit trail.
Which of the following situations requires an incident report in addition to standard progress notes?
Answer: A client experiencing a fall or injury on facility grounds
Incidents such as client falls, injuries, or safety events require a separate incident report to document the event and organizational response.