Documentation & Record Management Flashcards
7 cards from real CAS 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 & Record Management flashcards as text
Under 42 CFR Part 2, which of the following does NOT require patient consent before disclosing substance use disorder records?
Answer: Reporting a patient's child abuse to state authorities
42 CFR Part 2 contains an exception that permits disclosure without consent when mandatory child abuse reporting laws require it.
A counselor writes a progress note that reads: 'Client appeared unmotivated and resistant today.' What is the primary problem with this documentation?
Answer: It uses subjective, judgmental language rather than observable behavior
Progress notes should describe observable behaviors rather than subjective interpretations like 'unmotivated,' which are clinician judgments, not facts.
Which element is REQUIRED in a legally defensible informed consent document for SUD treatment?
Answer: A description of the risks and benefits of proposed treatment
Informed consent must include risks, benefits, and alternatives of treatment so the client can make a voluntary, informed decision.
A patient's legal guardian requests to inspect the minor's SUD treatment records. Under 42 CFR Part 2, the counselor should:
Answer: Deny access unless the minor consents, if the minor applied for treatment independently
42 CFR Part 2 protects minors who independently seek SUD treatment; a guardian's authority may not override that confidentiality without the minor's consent.
Which of the following best describes the purpose of a biopsychosocial assessment in clinical documentation?
Answer: To provide a comprehensive baseline for treatment planning across biological, psychological, and social domains
A biopsychosocial assessment captures the full range of factors influencing addiction and recovery to guide individualized treatment planning.
An audit reveals that a counselor routinely back-dates progress notes to match the date of service. This practice is BEST described as:
Answer: Fraudulent documentation that violates ethical and legal standards
Back-dating records constitutes falsification of medical documents, which is both unethical and potentially criminal under healthcare fraud statutes.
Which type of progress note format requires the counselor to document Subjective data, Objective data, Assessment, and Plan?
Answer: SOAP
SOAP stands for Subjective, Objective, Assessment, and Plan, and is a widely used structured format in healthcare documentation.