Documentation and Confidentiality Flashcards

Which of the following scenarios describes a breach of confidentiality?

Answer: An RSS mentions to a neighbor that a mutual friend is enrolled in a recovery program

Disclosing that a specific individual is enrolled in a recovery program to an unauthorized person violates confidentiality, even without sharing clinical details.

A mandatory reporting law requires an RSS to report suspected child abuse. After making the report, the RSS should:

Answer: Document the report, including what information was shared, to whom, and when

Mandatory reports must be documented in the record, including the nature of the concern, who was notified, and when the report was made.

How long must a recovery support agency typically retain client records after the last date of service?

Answer: The period specified by applicable state law and agency policy, commonly 7–10 years for adults

Record retention periods vary by state law and funding requirements but commonly range from 7 to 10 years for adult client records.

A client's consent for release of information has expired. The RSS receives a request for records from the consented recipient. The RSS should:

Answer: Obtain a new, current consent from the client before releasing any records

An expired consent is no longer valid; a new consent must be obtained before any additional disclosures can be made.

Which statement about 42 CFR Part 2 and HIPAA is accurate?

Answer: 42 CFR Part 2 provides stricter protections specifically for substance use disorder records than HIPAA's general privacy rule

42 CFR Part 2 imposes stricter consent and disclosure requirements for substance use disorder records than HIPAA's general health information protections.

An RSS is asked to sign as a witness on a client's consent form. By signing, the RSS is attesting that:

Answer: The client signed the form voluntarily and the RSS witnessed the signature

A witness signature on a consent form attests only that the person signed voluntarily; it does not imply the witness endorses the decision.

What is the recommended practice when an RSS receives a fax containing another client's records by mistake?

Answer: Notify the sender, document the misdirected fax, and follow agency policy for secure destruction of the records

Misdirected records must be reported to the sender immediately, documented, and securely destroyed according to agency policy to prevent unauthorized disclosure.