Education and Documentation Flashcards
6 cards from real LCDC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Education and Documentation flashcards as text
Which statement about Electronic Health Records (EHRs) in substance use settings is accurate?
Answer: EHRs must comply with both HIPAA and 42 CFR Part 2 when containing substance use treatment information
EHRs containing substance use treatment data must meet the heightened confidentiality requirements of 42 CFR Part 2, which are more restrictive than standard HIPAA.
Education about naloxone (Narcan) for clients and families should emphasize:
Answer: How to recognize an overdose, how to administer naloxone, and the importance of calling 911
Naloxone education focuses on overdose recognition, correct administration technique, and the critical step of calling emergency services after use.
When writing clinical notes, which practice most protects the counselor and client?
Answer: Documenting only clinically relevant, factual observations in objective language
Objective, factual documentation protects both the client's rights and the counselor's legal standing while maintaining professional standards.
Which type of family education is most evidence-based for improving treatment engagement of a resistant client?
Answer: Community Reinforcement and Family Training (CRAFT)
CRAFT teaches family members positive communication and reinforcement strategies that have been shown to increase treatment entry rates for resistant individuals.
The DAP note format used in addiction counseling stands for:
Answer: Data, Assessment, Plan
DAP notes organize clinical documentation into observable data, the counselor's clinical assessment, and the plan for next session or follow-up.
When facilitating psychoeducation about opioid use disorder and MAT, the counselor should convey that:
Answer: MAT is a legitimate evidence-based treatment that reduces mortality and supports recovery
MAT with buprenorphine, methadone, or naltrexone reduces overdose deaths, criminal activity, and disease transmission and is endorsed by SAMHSA and ASAM.