Master Addiction Counselor Exam Case Management and Documentation 1

Question 1

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

Accepted Answer

Progress notes

Answer

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?

Accepted Answer

Minimum necessary information

Answer

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:

Accepted Answer

Case management

Answer

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?

Accepted Answer

Date, signature, and credentials of the counselor

Answer

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:

Accepted Answer

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

Answer

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.

Master Addiction Counselor Exam Practice Test

Master Addiction Counselor Exam Practice Test

Master Addiction Counselor Exam Case Management and Documentation 1