Documentation and Case Management Flashcards
7 cards from real CADC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation and Case Management flashcards as text
Under HIPAA, which of the following is considered Protected Health Information (PHI)?
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.
Which element is MOST critical to include in a treatment plan to ensure it is measurable?
Answer: Specific, observable behavioral goals with target dates
Measurable treatment plans require specific, observable behavioral goals with target dates to track progress objectively.
When a client discloses they plan to harm a specific, identifiable third party, the counselor's duty to warn typically requires:
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.
Which type of case management model positions the counselor as a direct provider who personally delivers most services to the client?
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.
In the SOAP note format, subjective information refers to:
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.
A release of information (ROI) form is INVALID if it is missing which of the following components?
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.
Which of the following BEST describes the purpose of a biopsychosocial assessment in substance use counseling documentation?
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.