NCCAP ADC flashcards
NCCAP ADC · Build recall with a focused review session.
32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Screening
- A brief, standardized process used to determine whether a client needs a fuller assessment or immediate attention. It does not establish a diagnosis or a treatment plan.
- Informed consent elements
- Purpose, procedures, risks and benefits, limits of confidentiality, right to refuse or withdraw, and alternatives. Consent is documented and renewed when services change materially.
- 42 CFR Part 2
- Federal confidentiality rule for substance use disorder treatment records. It is stricter than HIPAA and generally requires specific written client consent before disclosure to outside parties.
- ASAM Dimension 1
- Intoxication and withdrawal potential. It assesses current intoxication, withdrawal risk, and whether medical monitoring is needed to determine the appropriate level of care.
- Intake documentation
- The record of identifying data, presenting problem, substance use and treatment history, medical and psychiatric history, legal status, risk screening, and the client's stated goals.
- DSM-5-TR severity thresholds
- Substance use disorder is mild at 2-3 criteria, moderate at 4-5, and severe at 6 or more criteria met within a 12-month period.
- Tolerance and withdrawal exception
- These criteria are not counted when the substance is taken solely as prescribed and under appropriate medical supervision, such as prescribed opioids or benzodiazepines.
- Six ASAM dimensions
- Intoxication and withdrawal, biomedical conditions, emotional/behavioral/cognitive conditions, readiness to change, relapse potential, and recovery environment. They guide level-of-care matching.
- Differential diagnosis
- Ruling out conditions that mimic intoxication or withdrawal, such as hypoglycemia, head injury, sepsis, and psychiatric disorders, before assigning a substance-related diagnosis.
- Collateral information
- Data from family, employers, or records used to supplement self-report, which may be affected by denial, minimization, or impaired recall. Consent is required to contact others.
- Alcohol withdrawal risk
- Alcohol and sedative withdrawal can be life-threatening, causing seizures and delirium tremens. These require medical management rather than outpatient-only care.
- Goal versus objective
- A goal is a broad desired outcome. An objective is a specific, measurable, time-bound step that shows progress toward the goal and can be evaluated.
- Level of care matching
- Selecting outpatient, intensive outpatient, residential, or medically managed services by matching ASAM dimension findings to the ASAM Criteria. Departures require documented rationale.
- Treatment plan review
- The plan is revised when the client changes level of care, meets or fails objectives, or has a significant change in condition. Reviews are documented with dates.
- Discharge planning timing
- Discharge and continuing care planning begins at admission, identifying anticipated referrals, recovery supports, and criteria for successful completion.
- Behavioral problem statements
- Treatment plan problems are written in observable, behavioral terms rather than labels or judgments, so that progress can be measured objectively.
- Stages of change
- Precontemplation, contemplation, preparation, action, and maintenance, with relapse as a possible return to earlier stages. Interventions are matched to the client's current stage.
- Motivational interviewing
- A directive, client-centered style using open questions, affirmations, reflections, and summaries to elicit change talk and strengthen the client's own motivation rather than arguing.
- Lapse versus relapse
- A lapse is a single return to use; a relapse is a return to the previous pattern. Both are treated as learning events and addressed in the plan.
- Contingency management
- A behavioral approach that provides defined, pre-specified rewards for verified abstinence or treatment attendance. Rewards and verification methods are documented in advance.
- Warm handoff
- Directly connecting a client to the receiving provider, such as by joint contact or scheduled appointment made together, rather than giving a referral list.
- Referral follow-up
- Confirming that the client attended and received the referred service. An unconfirmed referral is not a completed linkage and is documented as pending.
- Case management functions
- Assessment, planning, linking to services, monitoring progress, and advocacy. The case manager coordinates care rather than delivering every service personally.
- Referral documentation
- Recording the referral date, receiving agency, reason, information shared, and outcome, including whether the client attended and any barriers encountered.
- Naloxone education
- Teaching recognition of opioid overdose, administration of naloxone, and calling emergency services. It is provided to clients and family where overdose risk exists.
- Family education content
- Enabling behaviors, boundary setting, communication skills, and support resources such as Al-Anon and Nar-Anon. Sharing client information still requires written consent.
- Teach-back method
- Asking the learner to explain the material in their own words. It verifies comprehension more reliably than asking whether the material was understood.
- Record correction method
- Draw a single line through the error, write the correction, and initial and date it. Never obliterate, white out, or delete the original entry.
- Late entry
- A note written after the service date. It is labeled as late and includes both the date of entry and the date the service occurred.
- Release of information
- A written, signed, time-limited authorization specifying the recipient, the information to be disclosed, and the purpose. It must comply with applicable federal and state law.
- Duty to warn
- The obligation, triggered by a credible threat to an identifiable person, to take protective steps specified by state law, such as warning the person or notifying authorities.
- Scope of practice
- The range of services a counselor is trained and credentialed to provide. Needs beyond that range are referred rather than attempted without competence.