Documentation, Confidentiality & Record-Keeping Flashcards

A recovery coach receives a subpoena signed by an attorney requesting a participant's substance use records. Under 42 CFR Part 2, what is required before the records can be disclosed without the participant's consent?

Answer: A court order meeting Part 2 requirements

Under Part 2, a subpoena alone is not enough; a court order issued under Part 2's specific standards is required to compel disclosure without consent.

A participant collapses during a coaching session and EMTs ask whether he uses opioids. Which Part 2 provision allows the coach to share relevant information without written consent?

Answer: The medical emergency exception

Part 2 permits disclosure to medical personnel to the extent needed to treat a bona fide medical emergency when consent cannot be obtained.

Which progress note entry best reflects objective, professional documentation?

Answer: Participant arrived 20 minutes late and stated, 'I didn't sleep last night.'

Objective notes record observable behavior and direct quotes rather than judgments or assumptions.

A coach realizes a note entered yesterday contains an incorrect date in a paper record. What is the proper way to correct it?

Answer: Draw a single line through the error, write the correction, and initial and date it

A single line keeps the original entry readable while documenting who made the change and when, preserving record integrity.

A participant's mother calls asking whether her adult son attended his coaching session today. No release is on file. What should the coach do?

Answer: Neither confirm nor deny that the person is a participant

Under Part 2, even acknowledging that someone receives substance use services is a protected disclosure without consent.

Which element is required in a valid 42 CFR Part 2 consent form?

Answer: A description of the information to be disclosed

A Part 2 consent must specify what information will be disclosed, along with who receives it, its purpose, signature, date, and expiration.

When should a recovery coach complete documentation of a session?

Answer: As soon as possible after the session, ideally the same day

Timely documentation improves accuracy and supports continuity of care and accountability.