CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 4 — Questions and Answers
Question 1: Which scenario represents a proper use of 'qualified service organization agreements' (QSOAs) under 42 CFR Part 2?
- A program shares records with a billing company that signs a QSOA agreeing to be bound by 42 CFR Part 2 (Correct answer)
- A counselor verbally tells a lab the client's name without documentation
- A program posts client names on a public appointment board
- An administrator emails unencrypted records to an outside agency without consent
Correct answer: A program shares records with a billing company that signs a QSOA agreeing to be bound by 42 CFR Part 2
A QSOA allows a program to share necessary information with service organizations (such as billing companies) when the organization agrees in writing to comply with 42 CFR Part 2.
Question 2: A counselor is required to maintain records for a minimum period after discharge. This period is primarily governed by:
- The counselor's personal preference
- State law and program policy, which may vary by jurisdiction (Correct answer)
- Federal law mandating exactly three years for all programs
- The client's request at discharge
Correct answer: State law and program policy, which may vary by jurisdiction
Record retention requirements are set by state law, accreditation standards, and program policy, and may differ significantly from state to state.
Question 3: Which of the following BEST describes 'DAP' format in progress notes?
- Diagnosis, Assessment, Plan
- Data, Assessment, Plan (Correct answer)
- Description, Action, Progress
- Drug history, Abstinence goal, Prognosis
Correct answer: Data, Assessment, Plan
DAP notes are structured as Data (objective and subjective information), Assessment (clinical interpretation), and Plan (next steps in treatment).
Question 4: When a client signs a release of information authorizing disclosure to their primary care physician, the authorization is generally valid for:
- An unlimited period unless the client revokes it
- The time period specified on the authorization form (Correct answer)
- Exactly 90 days regardless of what the form states
- Only one disclosure event within the week it is signed
Correct answer: The time period specified on the authorization form
A valid authorization must include an expiration date or event, and disclosures are permitted only within the scope and time period specified.
Question 5: A client verbally revokes their consent for a release of information. The counselor should:
- Ignore the verbal revocation and continue sharing information
- Honor the revocation immediately and document it in writing (Correct answer)
- Require the client to submit a notarized letter before stopping disclosure
- Contact the receiving party to ask whether to continue sharing
Correct answer: Honor the revocation immediately and document it in writing
Clients may revoke consent at any time; the counselor must stop disclosures immediately and document the revocation in the record.
Question 6: Which of the following is an example of a breach of confidentiality NOT covered by a recognized exception?
- Reporting a client's HIV status to a known sexual partner per state law
- Disclosing a client's treatment status to their landlord at the landlord's request (Correct answer)
- Sharing session information in clinical supervision within the program
- Notifying police of a client's credible, specific threat to kill an identified person
Correct answer: Disclosing a client's treatment status to their landlord at the landlord's request
Sharing a client's treatment information with their landlord does not fall under any recognized exception and constitutes an unauthorized disclosure.
Question 7: Electronic health records (EHR) used in substance abuse treatment must comply with 42 CFR Part 2 by:
- Removing all 42 CFR Part 2 data from EHR systems to avoid liability
- Implementing access controls and audit trails to prevent unauthorized disclosure (Correct answer)
- Allowing all clinical staff across a health system to view records without restriction
- Storing records on publicly accessible cloud servers for emergency access
Correct answer: Implementing access controls and audit trails to prevent unauthorized disclosure
EHR systems holding 42 CFR Part 2 data must have role-based access controls and audit trails to ensure only authorized disclosures occur.
CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 4
Which scenario represents a proper use of 'qualified service organization agreements' (QSOAs) under 42 CFR Part 2?