Documentation & Record Keeping Flashcards
7 cards from real AK practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Keeping flashcards as text
Under HIPAA, how long must an applied kinesiologist retain adult patient records in most US states?
Answer: 6 years from date of creation or last effective date
HIPAA requires covered entities to retain medical record documentation for 6 years from creation or last effective date, whichever is later.
Which element is MOST critical to include when documenting a manual muscle test (MMT) result in an AK session?
Answer: Specific muscle tested, grade assigned, and side (left/right)
Documenting the specific muscle, its MMT grade, and laterality ensures reproducibility and clinical accuracy of the finding.
A patient requests a copy of their AK records. Under HIPAA, the practitioner must typically provide access within:
Answer: 30 days, with one 30-day extension if needed
HIPAA grants covered entities 30 days to respond to a patient access request, with one permissible 30-day extension.
When recording a therapy localization (TL) finding, the practitioner should document:
Answer: The anatomical site, resulting change in muscle response, and clinical interpretation
Complete TL documentation includes the site contacted, the indicator muscle response change, and the clinical significance to support diagnostic reasoning.
Which statement best describes the purpose of a problem-oriented medical record (POMR) in AK practice?
Answer: It organizes patient data around identified clinical problems to track progress systematically
A POMR structures records around each clinical problem, allowing systematic tracking of AK findings and treatment outcomes over time.
An AK practitioner adds a late entry to a patient's chart two days after the visit. Best practice requires:
Answer: Labeling it clearly as a late entry with the current date and reason for delay
Late entries must be labeled as such with the actual date written and an explanation for the delay to preserve record integrity.
What does the 'O' section of a SOAP note primarily contain in an AK context?
Answer: Objective findings such as MMT grades, postural analysis, and TL results
The Objective section records measurable, observable findings — in AK this includes MMT grades, postural deviations, and challenge/TL results.