CDCA CDCA Case Management & Documentation 2

Question 1

Progress notes in substance use disorder treatment should be written using which format to ensure clinical utility and legal defensibility?

Accepted Answer

SOAP (Subjective, Objective, Assessment, Plan) or an equivalent structured format

Answer

A narrative paragraph with no headers

Answer

Only bullet points listing client complaints

Answer

A weekly summary without session-specific details

Question 2

According to 42 CFR Part 2, which of the following is TRUE regarding substance use disorder patient records?

Accepted Answer

They receive stronger confidentiality protections than general medical records

Answer

They can be shared freely among all healthcare providers without consent

Answer

They are subject to the same rules as general criminal records

Answer

They do not require any special consent for release

Question 3

A client discloses during a session that they relapsed last week but does not want it documented. The CDCA should:

Accepted Answer

Document the relapse accurately in the clinical record as it is clinically relevant and ethically required

Answer

Honor the client's request and omit the relapse from all documentation

Answer

Terminate services immediately due to noncompliance

Answer

Report the client to their probation officer without further discussion

Question 4

What is the primary purpose of a discharge summary in substance use disorder treatment?

Accepted Answer

To summarize the client's treatment course, progress toward goals, and recommendations for aftercare

Answer

To formally close the billing account with the insurance company

Answer

To notify law enforcement that the client has completed treatment

Answer

To record only the reasons why the client left treatment

Question 5

Which of the following is an example of appropriate clinical documentation language?

Accepted Answer

'Client reported consuming 6 beers daily for the past week and expressed ambivalence about reducing use.'

Answer

'Client is a hopeless alcoholic who refuses to cooperate.'

Answer

'Client seems like they are lying about their drinking.'

Answer

'Client's family says they drink too much.'

Question 6

How long are substance use disorder treatment records typically required to be retained in the US?

Accepted Answer

Retention requirements vary by state but are commonly 7 years or more after discharge

Answer

Records must be destroyed after 1 year to protect client privacy

Answer

Only active client records need to be kept; closed records can be discarded immediately

Answer

Federal law requires exactly 3 years of retention for all SUD records