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 asked to provide a progress report to a third-party insurer funding rehabilitation services. What must occur first?
Answer: Obtain the client's written authorization specifying what information may be released
The client must provide written authorization specifying what information can be disclosed before any records or reports are released to a third-party insurer.
Which action best demonstrates a kinesiologist's adherence to the principle of 'minimum necessary information' under PHIPA?
Answer: Providing only the specific information required for the stated purpose of the request
The principle of minimum necessary information requires that only the information needed for the specific stated purpose be disclosed, not the entire record.
A kinesiologist documents that a client 'performed poorly' during a session. Why is this type of language problematic?
Answer: It is subjective, unprofessional, and not measurable
Vague, judgmental language like 'performed poorly' is unprofessional and lacks measurable criteria; documentation should use objective, measurable terms.
When must a kinesiologist update a client's health history documentation?
Answer: Whenever significant changes in the client's health status occur
Health history documentation must be updated whenever there are significant changes in a client's health status, medications, or relevant medical history.
A client verbally revokes their consent for a specific intervention mid-program. How should this be documented?
Answer: Note the revocation in the session record including the date, nature of the revocation, and any discussion that occurred
Verbal revocation of consent must be documented in the session record with the date, specifics of what was revoked, and any relevant discussion to maintain an accurate clinical and legal record.
Which of the following is an example of appropriate use of abbreviations in kinesiology documentation?
Answer: Using widely recognized, standardized professional abbreviations consistently throughout records
Using widely recognized, standardized abbreviations ensures clarity and reduces the risk of misinterpretation by other professionals reviewing the records.
In kinesiology practice, what is the role of documentation in supporting continuity of care?
Answer: It provides an accurate, accessible record enabling consistent and informed care across providers and sessions
Thorough documentation provides a continuous record of assessment findings, interventions, and outcomes that enables consistent, informed care across multiple sessions or care providers.