CRSS Documentation and Confidentiality 2 — Questions and Answers
Question 1: Under 42 CFR Part 2, which action requires explicit written consent from the client?
- Sharing records with the client's employer (Correct answer)
- Disclosing records to another substance use disorder treatment provider for continued care
- Reporting a communicable disease to a public health authority as required by law
- Discussing a client's progress in a clinical supervision session without identifying information
Correct 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.
Question 2: A recovery support specialist discovers an error in a client's case note from the previous week. The best practice is to:
- Delete the original note and rewrite it correctly
- Draw a single line through the error, write the correction, and add initials and date (Correct answer)
- White out the mistake and write the correction over it
- Leave the error uncorrected to preserve the original record
Correct 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.
Question 3: Which of the following is NOT typically included in a progress note written by a recovery support specialist?
- The client's response to the support provided
- A clinical diagnosis or diagnostic impression (Correct answer)
- Goals addressed during the contact
- Date and duration of the contact
Correct 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.
Question 4: A client verbally consents to releasing information but refuses to sign a written release form. What should the RSS do?
- Proceed with the disclosure since verbal consent is sufficient
- Document the verbal consent in the record and proceed
- Decline to release the information and document the client's refusal to sign (Correct answer)
- Contact the supervisor to override the client's decision
Correct 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.
Question 5: When documenting a home visit in a client's record, the RSS should primarily focus on:
- Personal opinions about the client's living environment
- Objective observations related to recovery goals and services provided (Correct answer)
- Comparisons between the client's home and those of other clients
- Speculations about the client's future behavior
Correct 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.
Question 6: A subpoena is received for a client's substance use disorder treatment records covered under 42 CFR Part 2. The RSS should:
- Release the records immediately to comply with the court order
- Notify the client and consult with the program's legal counsel before releasing anything (Correct answer)
- Refuse all court orders since 42 CFR Part 2 overrides all legal processes
- Release only the dates of service and withhold all other information
Correct 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.
Question 7: Which documentation practice best demonstrates that services were 'medically necessary' or goal-directed for billing and audit purposes?
- Recording that the client appeared happy during the session
- Linking each service provided to a specific recovery plan goal or objective (Correct answer)
- Noting the RSS's personal feelings about the client's progress
- Documenting the weather and travel time to the appointment
Correct 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.
CRSS Documentation and Confidentiality 2
Under 42 CFR Part 2, which action requires explicit written consent from the client?