Download CADC – Documentation Questions with 100% Correct Answers | Updated & Verified | 2025- 2026 and more Exams Medicine in PDF only on Docsity!
CADC – Documentation Questions with 100%
Correct Answers | Updated & Verified | 2025 -
Roles of documentation - ✔✔1. clinical tool
- continuity of care
- legal document
- accountability
- quality assurance
Documentation as a clinical tool - ✔✔chronologically details the condition of the client receiving services, why the services were needed, services provided who delivered the services, and outcomes achieved.
- used in supervision
- most important skill in assuring continuity of care
Documentation as means to ensure continuity of care - ✔✔ensures continuity of care, regardless of counselor availability, changes in counselor or service provider or subsequent readmission for services.
- EASES the TRANSITION PROCESS ensuring pertinent info is available to receiving counselor/program
Documentation as a legal document - ✔✔records both counselor and client input, including what did/did not work.
- portions of clt record may be requested by courts if clt is legally involved or in cases where the clt brings legal proceedings against a counselor/program
Documentation as accountability - ✔✔recording information that is used for billing purposes, financial audits or reviews to ensure compliance with various standards.
- document time, date, duration & type of insurance
Documentation for quality assurance - ✔✔the clt record provides documentation for quality assurance reviews including utilization review, peer review, and clinical supervision.
- processes assess if the type, intensity, duration of services are appropriate for client's condition and if documents meet regulatory and agency expectations.
In IL, how long are treatment records retained? - ✔✔5 years after discharge, excluding the accounting of disclosures protected by HIPPA which must be retained for 6 years.
In IL, How long are medical records detained? - ✔✔7 years
Screening - ✔✔Occurs at INITIAL CONTACT, purpose is to gather enough preliminary information about the clt to evaluate their need for services, eligibility for services, and appropriate level of care/service placement.
- Focuses on CURRENT INFO regarding the PRESENTING PRBLM and the PRBLM ACUITY that resulted in the clt seeking or being referred to treatment
Elements of screening documentation - ✔✔1. Referral source
- Presenting problems/problem acuity
- Background information (vocational, legal, family, living environment)
- Emotional/mental status (degree of danger to self/others, ability to participant in tx)
- Client strengths and preferences
