Documentation and Confidentiality Flashcards

Under 42 CFR Part 2, which action requires explicit written consent from the client?

Answer: Sharing records with the client's employer

42 CFR Part 2 requires written patient consent before disclosing substance use disorder records to an employer, even with a release in another area.

A recovery support specialist discovers an error in a client's case note from the previous week. The best practice is to:

Answer: Draw a single line through the error, write the correction, and add initials and date

Standard documentation practice requires a single line through errors with a correction, initials, and date so the original entry remains legible.

Which of the following is NOT typically included in a progress note written by a recovery support specialist?

Answer: A clinical diagnosis or diagnostic impression

Recovery support specialists are not licensed to diagnose; clinical diagnoses are made by credentialed clinicians and documented separately.

A client verbally consents to releasing information but refuses to sign a written release form. What should the RSS do?

Answer: Decline to release the information and document the client's refusal to sign

Most regulations, including 42 CFR Part 2 and HIPAA, require written consent for disclosures; verbal consent alone is not sufficient.

When documenting a home visit in a client's record, the RSS should primarily focus on:

Answer: Objective observations related to recovery goals and services provided

Documentation should be objective and tied to recovery-related services rather than subjective judgments or irrelevant observations.

A subpoena is received for a client's substance use disorder treatment records covered under 42 CFR Part 2. The RSS should:

Answer: Notify the client and consult with the program's legal counsel before releasing anything

A subpoena alone does not override 42 CFR Part 2 protections; the program must seek a court order meeting specific criteria and typically notifies the client first.

Which documentation practice best demonstrates that services were 'medically necessary' or goal-directed for billing and audit purposes?

Answer: Linking each service provided to a specific recovery plan goal or objective

Tying each documented service to a recovery plan goal demonstrates purposeful, goal-directed support and satisfies audit requirements.