Case Management and Documentation Flashcards
6 cards from real MAC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Case Management and Documentation flashcards as text
Which type of documentation is used to record a client's progress toward treatment goals between sessions?
Answer: Progress notes
Progress notes document a client's ongoing status, interventions used, and movement toward treatment goals after each session.
Under HIPAA, which of the following is the minimum standard for releasing client records to a third party?
Answer: Minimum necessary information
HIPAA's minimum necessary standard requires that only the information needed for the specific purpose be disclosed when releasing records.
A MAC counselor coordinates housing, employment services, and medical care for a client. This is best described as:
Answer: Case management
Case management involves coordinating a range of community services—medical, social, and vocational—to support a client's overall recovery.
Which element is essential in a legally defensible clinical record?
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.
A counselor discovers an error in a previously written progress note. The correct action is to:
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.
Which federal regulation specifically governs the confidentiality of substance use disorder treatment records?
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.