Documentation & Record Management Flashcards

A subpoena is issued for a client's SUD treatment records. Under 42 CFR Part 2, the counselor should:

Answer: Consult legal counsel and not release records unless accompanied by a court order meeting 42 CFR Part 2 requirements or client consent

A subpoena alone is insufficient to release SUD records under 42 CFR Part 2; a court order that meets specific criteria or patient consent is required.

Which of the following BEST reflects the DAP progress note format?

Answer: Data, Assessment, Plan

DAP stands for Data (objective and subjective observations), Assessment (clinical interpretation), and Plan (next steps), a common SUD counseling note format.

A client's record includes a note written by a previous counselor that the current counselor believes is inaccurate. The current counselor should:

Answer: Add an addendum to the record noting the disagreement without altering the original entry

Prior entries must not be altered; the appropriate response is to add a dated addendum documenting the clinician's clinical disagreement or correction.

Which of the following is the MOST appropriate timeframe standard for completing a progress note after a counseling session?

Answer: Within 24 hours or per the agency's documented policy

Best practice and most regulatory standards require progress notes to be completed within 24 hours of the session or according to the agency's established policy.

A counselor's agency begins transitioning from paper to electronic records. Which is the MOST important security measure to implement first for electronic SUD records?

Answer: Implementing role-based access controls so only authorized staff can view records

Role-based access controls restrict EHR access to authorized personnel only, protecting patient confidentiality as required by HIPAA and 42 CFR Part 2.

When a client transfers between two SUD treatment programs, the sending program may share records without patient consent ONLY if:

Answer: The programs are part of the same organization and the consent form covers the transfer

Under 42 CFR Part 2, records may be shared between components of the same organization without individual consent if the original consent covers this purpose.

Which of the following client behaviors should be documented in a progress note using behavioral rather than interpretive language?

Answer: 'Client raised his voice, crossed his arms, and declined to complete the worksheet.'

Behavioral language records observable actions (raised voice, crossed arms, declined task) rather than interpretations (angry, uncooperative) and is more defensible clinically and legally.