CAC Documentation and Record Keeping 1 — Questions and Answers
Question 1: Which type of progress note format structures documentation around Subjective, Objective, Assessment, and Plan?
- SOAP note (Correct answer)
- DAP note
- BIRP note
- PIE note
Correct answer: SOAP note
SOAP notes organize clinical documentation into four sections: Subjective (client's report), Objective (observable data), Assessment (clinical interpretation), and Plan (next steps).
Question 2: Under HIPAA, clients have the right to:
- Access and obtain a copy of their own protected health information (PHI) (Correct answer)
- Demand that providers delete all of their records
- Share their records with any third party without restrictions
- Prevent providers from using any information in their treatment
Correct answer: Access and obtain a copy of their own protected health information (PHI)
HIPAA's Privacy Rule grants clients the right to inspect and receive copies of their own PHI held by covered entities, with limited exceptions.
Question 3: Which principle requires that clinical documentation be completed as close to the time of service as possible?
- Timeliness (Correct answer)
- Accuracy
- Completeness
- Legibility
Correct answer: Timeliness
Timely documentation ensures that clinical information is recorded while details are fresh, reducing errors and supporting continuity of care.
Question 4: A DAP progress note includes which three sections?
- Data, Assessment, Plan (Correct answer)
- Diagnosis, Assessment, Prognosis
- Description, Analysis, Progress
- Data, Action, Progress
Correct answer: Data, Assessment, Plan
DAP notes organize information into Data (what happened in session), Assessment (clinical interpretation), and Plan (next steps or interventions).
Question 5: What does 'confidentiality' in addiction counseling protect?
- Information shared by the client in the course of treatment from unauthorized disclosure (Correct answer)
- The counselor from liability when clients relapse
- The identity of the counselor from public disclosure
- Information shared between counselors in supervision
Correct answer: Information shared by the client in the course of treatment from unauthorized disclosure
Confidentiality protects client-disclosed information from being shared with anyone outside the treatment relationship without the client's informed consent.
Question 6: Which type of release of information form is required specifically for substance use disorder records under 42 CFR Part 2?
- A consent form that specifies the program, recipient, purpose, what is to be disclosed, and expiration date (Correct answer)
- A standard HIPAA authorization form
- A verbal consent documented in the chart
- A blanket release signed at intake for all future disclosures
Correct answer: A consent form that specifies the program, recipient, purpose, what is to be disclosed, and expiration date
42 CFR Part 2 requires a specific consent form with precise elements including who is releasing, who is receiving, the purpose, and a defined expiration — blanket or generic forms do not suffice.
CAC Documentation and Record Keeping 1
Which type of progress note format structures documentation around Subjective, Objective, Assessment, and Plan?