CRSS Documentation and Confidentiality 2

Question 1

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

Accepted Answer

Sharing records with the client's employer

Answer

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:

Accepted Answer

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

Answer

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?

Accepted Answer

A clinical diagnosis or diagnostic impression

Answer

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?

Accepted Answer

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

Answer

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:

Accepted Answer

Objective observations related to recovery goals and services provided

Answer

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

CRSS - Certified Recovery Support Specialist Practice Test