Documentation & Record Management Flashcards
7 cards from real CAS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Management flashcards as text
A client signs a release of information allowing the counselor to speak with their probation officer. The client later verbally revokes this consent. The counselor should:
Answer: Honor the revocation immediately for future disclosures while documenting it in the record
Consent can be revoked at any time, and the counselor must stop future disclosures and document the revocation, though prior disclosures made in good faith remain valid.
When documenting a client's relapse in a progress note, the CAS counselor should FIRST:
Answer: Record the facts objectively, including substances used, amount, and context
Objective, factual documentation of a relapse—substance, quantity, circumstances—provides the clinical basis for adjusting the treatment plan.
HIPAA's minimum necessary standard requires that disclosures of protected health information should:
Answer: Be limited to the least amount of information needed to accomplish the intended purpose
The minimum necessary standard mandates that only the PHI required for the specific purpose be shared, protecting patient privacy.
Which situation would MOST likely require a mandatory report that overrides 42 CFR Part 2 confidentiality protections?
Answer: A client states they plan to physically harm an identified third party
Duty-to-warn obligations triggered by a credible, specific threat to an identified third party can override SUD confidentiality protections.
A signed consent form for release of SUD records is valid under 42 CFR Part 2 only if it includes:
Answer: The name of the person or organization authorized to receive the information
42 CFR Part 2 requires that a valid consent identify the specific person or entity authorized to receive the disclosed information.
A CAS counselor discovers an error in a previously signed progress note. The CORRECT way to correct this error is to:
Answer: Draw a single line through the error, initial it, date it, and write the correction
Proper error correction in clinical records involves a single strikethrough, initials, and date—preserving the original entry while noting the correction.
Which statement BEST describes the relationship between a treatment plan and progress notes?
Answer: Progress notes document the client's response to interventions identified in the treatment plan
Progress notes should consistently reference and reflect movement toward or away from the goals and interventions established in the treatment plan.