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 HIPAA, which of the following is classified as Protected Health Information (PHI)?
Answer: A client's name linked to their SUD diagnosis in any format
PHI is any individually identifiable health information, including a client's name combined with a health condition, regardless of the medium.
A new client refuses to sign a release of information to allow communication with their prescribing physician. The counselor should:
Answer: Document the refusal and proceed with treatment while respecting the client's autonomy
Clients have the right to refuse releases; the counselor should document the refusal and continue treatment, while discussing potential clinical implications.
Which of the following elements is MOST essential in a discharge summary for a client completing residential SUD treatment?
Answer: A summary of treatment provided, progress toward goals, and aftercare plan
A discharge summary must capture the treatment course, goal attainment, and a concrete aftercare plan to support continuity of care.
Which federal regulation specifically governs the confidentiality of substance use disorder patient records in federally assisted programs?
Answer: 42 CFR Part 2 (Confidentiality of Substance Use Disorder Patient Records)
42 CFR Part 2 provides SUD-specific confidentiality protections that are stricter than HIPAA for federally assisted programs.
A counselor is documenting a group therapy session. Which approach best protects the confidentiality of all group members?
Answer: Write a general note describing group themes and the identified client's participation without naming other members
Group session notes should describe the client's participation and group themes without identifying or quoting other members to protect their confidentiality.
What is the primary clinical purpose of documenting treatment plan reviews at regular intervals?
Answer: To assess client progress, update goals, and adjust interventions based on outcomes
Regular treatment plan reviews ensure that goals remain relevant and that interventions are adjusted based on the client's evolving needs and progress.
An electronic health record system requires counselors to use drop-down menus for most documentation. A counselor notices the available options do not capture a clinically important detail. The BEST action is to:
Answer: Use a free-text or addendum field to document the clinically relevant detail not captured by the drop-down
When EHR templates don't capture clinically significant information, counselors should use available narrative or addendum fields to ensure complete, accurate documentation.