Record Keeping, Reporting, and Confidentiality
What this domain tests
Record keeping, reporting, and confidentiality test your knowledge of 42 CFR Part 2, HIPAA, consent, exceptions, retention, and client rights. SUD records receive stricter federal protection than general medical records.
Core rules
- 42 CFR Part 2 applies to federally assisted SUD programs; disclosure generally requires written consent naming the recipient and purpose.
- HIPAA permits treatment, payment, and operations uses; Part 2 does not automatically allow those without consent.
- Exceptions include medical emergencies, court orders, child abuse reporting, and certain audits.
- Clients have rights to access, amend, and receive an accounting of disclosures, subject to law and policy.
- Retain records per California Title 9 and program policy; verify current schedules rather than guessing.
Worked example
A probation officer calls asking whether a client attended treatment. Without a valid Part 2 consent or court order, the counselor confirms neither attendance nor identity and documents the call. Reasoning: the caller is not a covered exception, and confirming identity can itself disclose treatment.
Traps
Treating HIPAA as the only rule; sharing with family “because they are worried”; faxing or emailing without secure methods; and releasing records under a subpoena without legal review.