Documentation and Record Keeping Flashcards
7 cards from real COKO 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 and Record Keeping flashcards as text
A kinesiologist is working with a client who has a history of cardiac issues. Which element is MOST critical to document before beginning an exercise program?
Answer: Pre-participation health screening results and physician clearance
Pre-participation health screening results and any required physician clearance must be documented before initiating exercise programming for high-risk clients.
Under COKO standards, how long must client records generally be retained after the last date of service for an adult client?
Answer: 10 years
COKO standards align with Ontario regulations requiring records be kept for a minimum of 10 years after the last date of service for adult clients.
When documenting a client's subjective complaints, which format captures this information most systematically?
Answer: SOAP notes — the 'S' (Subjective) section
The 'S' (Subjective) section of a SOAP note is specifically designed to record the client's own reported symptoms, concerns, and history.
A kinesiologist inadvertently documents incorrect assessment values for a client. What is the appropriate correction method?
Answer: Draw a single line through the error, initial and date it, then add the correct information
Proper documentation correction requires drawing a single line through the error, initialing and dating it, then writing the correct information to maintain a clear audit trail.
Which type of consent must be documented before sharing a client's records with their employer?
Answer: Written informed consent from the client
Written informed consent from the client is required before disclosing their personal health information to any third party, including employers.
What does the 'A' (Assessment) section of a SOAP note typically contain?
Answer: The clinician's professional interpretation and clinical reasoning
The 'A' (Assessment) section reflects the kinesiologist's professional interpretation of subjective and objective findings.
Under Ontario privacy legislation, a client requests access to their own health records. How should a kinesiologist respond?
Answer: Provide access within a reasonable timeframe, typically 30 days
Under PHIPA, clients have the right to access their own health records, and practitioners must respond within 30 days of the request.