CADC Documentation and Case Management 3 — Questions and Answers
Question 1: Under 42 CFR Part 2, substance use disorder treatment records receive special protection because:
- They are owned by the insurance company paying for treatment
- Disclosure could harm patients by deterring them from seeking treatment (Correct answer)
- They are classified as mental health records under federal law
- They require annual renewal of consent by the client
Correct answer: Disclosure could harm patients by deterring them from seeking treatment
42 CFR Part 2 provides heightened confidentiality protections to encourage individuals to seek SUD treatment without fear of legal consequences.
Question 2: When documenting a client's discharge summary, which information is MOST important to include for continuity of care?
- The client's billing history and copayment amounts
- Goals achieved, unresolved issues, and aftercare recommendations (Correct answer)
- A list of all staff members who provided services
- The counselor's personal observations about the client's motivation
Correct answer: Goals achieved, unresolved issues, and aftercare recommendations
A discharge summary must document progress toward goals, remaining needs, and aftercare recommendations to support continuity of care.
Question 3: A counselor discovers a documentation error in a client's chart from a previous session. The CORRECT way to correct it is to:
- Use white-out to cover the error and write the correct information
- Draw a single line through the error, write the correction, and initial and date it (Correct answer)
- Remove the page and rewrite the entire note
- Leave the error unchanged and add a separate correction note
Correct answer: Draw a single line through the error, write the correction, and initial and date it
The standard for correcting medical records is a single line through the error with the correction, initials, and date — never obliterate the original.
Question 4: Which of the following BEST reflects the broker model of case management?
- The case manager provides all therapeutic services directly to the client
- The case manager links clients to community resources but does not provide direct services (Correct answer)
- The case manager focuses exclusively on the client's strengths and assets
- The case manager acts as both therapist and medication prescriber
Correct answer: The case manager links clients to community resources but does not provide direct services
In the broker model, the case manager's primary role is to assess needs and connect clients to appropriate community services without direct service provision.
Question 5: What is the PRIMARY purpose of documenting a client's informed consent before treatment begins?
- To protect the agency from liability in malpractice lawsuits
- To ensure the client understands and voluntarily agrees to treatment terms (Correct answer)
- To satisfy accreditation body requirements for the facility
- To establish the client's financial responsibility for services
Correct answer: To ensure the client understands and voluntarily agrees to treatment terms
Informed consent ensures clients voluntarily agree to treatment after understanding its nature, risks, benefits, and alternatives.
Question 6: A mandated client's probation officer calls requesting a progress update. The counselor should FIRST:
- Provide a verbal update since the referral came from the court
- Verify that a valid, signed release of information is on file (Correct answer)
- Fax a full treatment summary to comply with legal requirements
- Refuse all communication with third parties to protect confidentiality
Correct answer: Verify that a valid, signed release of information is on file
Even for court-mandated clients, a valid ROI signed by the client must be on file before disclosing any treatment information.
Question 7: Which ASAM criterion dimension addresses a client's readiness to change and treatment engagement?
- Dimension 1 — Acute Intoxication and Withdrawal Potential
- Dimension 5 — Relapse, Continued Use, or Continued Problem Potential
- Dimension 4 — Readiness to Change (Correct answer)
- Dimension 6 — Recovery/Living Environment
Correct answer: Dimension 4 — Readiness to Change
ASAM Dimension 4 specifically assesses the client's readiness and motivation to change substance use behavior.
CADC Documentation and Case Management 3
Under 42 CFR Part 2, substance use disorder treatment records receive special protection because: