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
Under PHIPA, which of the following is considered 'personal health information'?
Answer: Any identifying information about an individual's physical or mental health
PHIPA broadly defines personal health information as any identifying information relating to an individual's physical or mental health, regardless of its form or source.
A kinesiologist leaves a practice and wants to take copies of client files. What is the correct approach?
Answer: Obtain written client consent for any records transferred to a new practice
Client records belong to the client, and written consent must be obtained before transferring records to a new practice or location.
What is the primary purpose of documenting contraindications identified during a client assessment?
Answer: To protect the practitioner legally and guide safe program design
Documenting contraindications protects the client's safety, guides appropriate program modifications, and creates a record demonstrating the practitioner's due diligence.
When a minor client turns 18, what change occurs regarding their health record retention and access rights?
Answer: The individual assumes full rights over their personal health information
Upon reaching the age of majority, an individual assumes full control over their personal health information and all associated access rights.
A kinesiologist uses a cloud-based platform to store client records. Which PHIPA obligation is MOST relevant?
Answer: Implementing reasonable safeguards to protect records from unauthorized access
PHIPA requires health information custodians to implement reasonable administrative, technical, and physical safeguards to protect personal health information.
Which scenario constitutes a privacy breach requiring notification under Ontario law?
Answer: An unauthorized employee accesses and reads a client's health file
An unauthorized employee accessing a client's health file constitutes a privacy breach, which must be documented and reported under PHIPA.
What does 'need to know' mean in the context of health record access within a clinic?
Answer: Only staff directly involved in the client's care should access their records
The 'need to know' principle limits access to personal health information only to those staff directly involved in providing care to that specific client.