CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 5 — Questions and Answers
Question 1: A counselor suspects a colleague is accessing client records without a clinical need. The MOST appropriate first action is to:
- Confront the colleague publicly in a staff meeting
- Report the concern to the supervisor or privacy officer per program policy (Correct answer)
- Delete the colleague's access credentials immediately
- Discuss the suspicion with clients to gather evidence
Correct answer: Report the concern to the supervisor or privacy officer per program policy
Suspected unauthorized access to records should be reported through proper channels — typically to a supervisor or HIPAA privacy officer — for investigation.
Question 2: Which of the following must be included in a valid 42 CFR Part 2 consent form?
- The client's diagnosis in clinical terminology
- The name of the person or organization authorized to make the disclosure and the recipient (Correct answer)
- The signature of the client's insurance company representative
- A list of all other programs the client has attended
Correct answer: The name of the person or organization authorized to make the disclosure and the recipient
A valid 42 CFR Part 2 consent must identify who may disclose the information, to whom, the purpose, and the scope of what may be shared.
Question 3: The Duty to Warn (Tarasoff) obligation most commonly requires a counselor to:
- Warn all past victims of a client's historical violence
- Take reasonable steps to protect an identifiable third party from a credible, specific threat (Correct answer)
- File a police report anytime a client mentions anger toward another person
- Terminate treatment immediately upon any disclosure of violent ideation
Correct answer: Take reasonable steps to protect an identifiable third party from a credible, specific threat
Tarasoff and similar duty-to-warn laws apply when a client makes a credible, specific, and serious threat against an identifiable victim, requiring protective action.
Question 4: A client involved in a drug court program signs a consent allowing the treatment program to share information with the drug court. Under 42 CFR Part 2, this arrangement is:
- Illegal regardless of consent because drug courts are law enforcement
- Permissible because the client has provided valid written consent (Correct answer)
- Permissible only if the drug court is part of the same organization as the treatment program
- Prohibited because criminal justice entities can never receive 42 CFR Part 2 information
Correct answer: Permissible because the client has provided valid written consent
With a valid patient consent form meeting 42 CFR Part 2 requirements, treatment programs may share information with drug courts and other criminal justice entities.
Question 5: Which of the following BEST describes the purpose of a biopsychosocial assessment in clinical documentation?
- To satisfy billing requirements by listing DSM diagnoses only
- To gather comprehensive information about biological, psychological, and social factors influencing the client's substance use (Correct answer)
- To determine the client's ability to pay for treatment services
- To assign the client to a peer support group without further evaluation
Correct answer: To gather comprehensive information about biological, psychological, and social factors influencing the client's substance use
A biopsychosocial assessment collects holistic information across biological, psychological, and social domains to inform accurate diagnosis and individualized treatment planning.
Question 6: When a client is transferred between two substance abuse treatment programs, information sharing is permitted under 42 CFR Part 2 if:
- The receiving program is located in the same state
- The client provides written consent authorizing the transfer of records (Correct answer)
- The transferring counselor verbally confirms the client's identity
- Both programs are owned by the same parent company
Correct answer: The client provides written consent authorizing the transfer of records
A transfer of substance abuse treatment records to another program requires the client's written consent that meets all 42 CFR Part 2 requirements.
Question 7: Late entries in clinical documentation should be:
- Inserted between existing notes as if written on time
- Clearly marked as late entries with the date and time of the actual writing (Correct answer)
- Avoided entirely — if not written on time, the session should go undocumented
- Backdated to the date of the session to maintain chronological order
Correct answer: Clearly marked as late entries with the date and time of the actual writing
Late entries must be labeled as such with the actual date and time of writing to maintain the accuracy and integrity of the clinical record.
CADC Alcohol and Drug Counselor Clinical Documentation and Confidentiality 5
A counselor suspects a colleague is accessing client records without a clinical need.
The MOST appropriate first action is to: