Master Addiction Counselor Exam Case Management and Documentation

Question 1

Which type of documentation is used to record a client's progress toward treatment goals between sessions?

Accepted Answer

Progress notes

Answer

Intake assessment

Answer

Discharge summary

Answer

Referral letter

Question 2

Under HIPAA, which of the following is the minimum standard for releasing client records to a third party?

Accepted Answer

Minimum necessary information

Answer

All records on file

Answer

Only billing records

Answer

Verbal consent from the client

Question 3

A MAC counselor coordinates housing, employment services, and medical care for a client. This is best described as:

Accepted Answer

Case management

Answer

Individual therapy

Answer

Psychoeducation

Answer

Crisis stabilization

Question 4

Which element is essential in a legally defensible clinical record?

Accepted Answer

Date, signature, and credentials of the counselor

Answer

Client's insurance policy number only

Answer

Supervisor's approval on every note

Answer

Typed format exclusively

Question 5

A counselor discovers an error in a previously written progress note. The correct action is to:

Accepted Answer

Draw a single line through the error, write the correction, and initial and date the change

Answer

Use correction fluid to cover the error

Answer

Delete the note and rewrite it entirely

Answer

Ignore the error if it is minor

Question 6

Which federal regulation specifically governs the confidentiality of substance use disorder treatment records?

Accepted Answer

42 CFR Part 2

Answer

HIPAA Privacy Rule

Answer

ADA Title II

Answer

FERPA