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 federal regulation governs the confidentiality of substance use disorder patient records in the US?
Answer: 42 CFR Part 2
42 CFR Part 2 provides stricter confidentiality protections for substance use disorder records than HIPAA.
A client's treatment record may be disclosed without written consent in which of the following situations?
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.
What is the primary purpose of progress notes in a client's addiction treatment record?
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.
Which element is MOST important to include when documenting a client's refusal of a recommended service?
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.
How long must substance use disorder treatment records typically be retained under most US state regulations?
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.
When a client signs a release of information, what must the form include to be valid under 42 CFR Part 2?
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.