CADC Documentation and Case Management 2 — Questions and Answers
Question 1: Under HIPAA, which of the following is considered Protected Health Information (PHI)?
- A client's general diagnosis shared in a staff meeting without identifiers
- A client's name combined with their treatment dates (Correct answer)
- Aggregate statistical data about the counseling program
- Anonymous survey results about client satisfaction
Correct answer: A client's name combined with their treatment dates
PHI includes any individually identifiable health information such as a client's name combined with treatment dates.
Question 2: Which element is MOST critical to include in a treatment plan to ensure it is measurable?
- A broad statement of the client's presenting problem
- Specific, observable behavioral goals with target dates (Correct answer)
- The counselor's clinical impressions of the client
- A description of the client's family history
Correct answer: Specific, observable behavioral goals with target dates
Measurable treatment plans require specific, observable behavioral goals with target dates to track progress objectively.
Question 3: When a client discloses they plan to harm a specific, identifiable third party, the counselor's duty to warn typically requires:
- Documenting the threat in the chart without further action
- Notifying law enforcement and/or the intended victim (Correct answer)
- Waiting until the next session to reassess the threat
- Consulting a supervisor before taking any action
Correct answer: Notifying law enforcement and/or the intended victim
The Tarasoff duty-to-warn standard requires counselors to notify law enforcement and/or the intended victim of credible threats.
Question 4: Which type of case management model positions the counselor as a direct provider who personally delivers most services to the client?
- Broker model
- Strengths-based model
- Clinical case management model (Correct answer)
- Community support model
Correct answer: Clinical case management model
The clinical case management model integrates direct clinical services with coordination, with the counselor acting as both clinician and case manager.
Question 5: In the SOAP note format, subjective information refers to:
- The counselor's clinical assessment and diagnosis
- Objective test results and observable behaviors
- What the client reports about their own experience (Correct answer)
- The plan for future treatment interventions
Correct answer: What the client reports about their own experience
The 'S' in SOAP stands for subjective, which includes the client's self-reported symptoms, feelings, and concerns.
Question 6: A release of information (ROI) form is INVALID if it is missing which of the following components?
- The counselor's professional license number
- The specific purpose or need for the disclosure (Correct answer)
- The client's insurance policy number
- The name of the referring physician
Correct answer: The specific purpose or need for the disclosure
A valid ROI must specify the purpose or need for disclosure, as required by 42 CFR Part 2 and HIPAA regulations.
Question 7: Which of the following BEST describes the purpose of a biopsychosocial assessment in substance use counseling documentation?
- To determine the client's insurance reimbursement eligibility
- To provide a comprehensive foundation for individualized treatment planning (Correct answer)
- To satisfy court requirements for mandated clients only
- To document the counselor's qualifications for treating the client
Correct answer: To provide a comprehensive foundation for individualized treatment planning
A biopsychosocial assessment gathers comprehensive biological, psychological, and social history to inform individualized treatment planning.
CADC Documentation and Case Management 2
Under HIPAA, which of the following is considered Protected Health Information (PHI)?