Master Addiction Counselor Exam Case Management and Documentation 1 — Questions and Answers
Question 1: Which type of documentation is used to record a client's progress toward treatment goals between sessions?
- Progress notes (Correct answer)
- Intake assessment
- Discharge summary
- Referral letter
Correct answer: Progress notes
Progress notes document a client's ongoing status, interventions used, and movement toward treatment goals after each session.
Question 2: Under HIPAA, which of the following is the minimum standard for releasing client records to a third party?
- Minimum necessary information (Correct answer)
- All records on file
- Only billing records
- Verbal consent from the client
Correct answer: Minimum necessary information
HIPAA's minimum necessary standard requires that only the information needed for the specific purpose be disclosed when releasing records.
Question 3: A MAC counselor coordinates housing, employment services, and medical care for a client. This is best described as:
- Case management (Correct answer)
- Individual therapy
- Psychoeducation
- Crisis stabilization
Correct answer: Case management
Case management involves coordinating a range of community services—medical, social, and vocational—to support a client's overall recovery.
Question 4: Which element is essential in a legally defensible clinical record?
- Date, signature, and credentials of the counselor (Correct answer)
- Client's insurance policy number only
- Supervisor's approval on every note
- Typed format exclusively
Correct answer: Date, signature, and credentials of the counselor
A legally defensible record must include the date of service, the counselor's signature, and their professional credentials on each entry.
Question 5: A counselor discovers an error in a previously written progress note. The correct action is to:
- Draw a single line through the error, write the correction, and initial and date the change (Correct answer)
- Use correction fluid to cover the error
- Delete the note and rewrite it entirely
- Ignore the error if it is minor
Correct answer: Draw a single line through the error, write the correction, and initial and date the change
Proper clinical record correction requires a single line through the error, the correct information added, and the counselor's initials and date to maintain an accurate audit trail.
Question 6: Which federal regulation specifically governs the confidentiality of substance use disorder treatment records?
- 42 CFR Part 2 (Correct answer)
- HIPAA Privacy Rule
- ADA Title II
- FERPA
Correct answer: 42 CFR Part 2
42 CFR Part 2 provides stricter confidentiality protections for records related to substance use disorder treatment programs that receive federal assistance.
Master Addiction Counselor Exam Case Management and Documentation 1
Which type of documentation is used to record a client's progress toward treatment goals between sessions?