AK Documentation & Record Keeping 2 — Questions and Answers
Question 1: Under HIPAA, how long must an applied kinesiologist retain adult patient records in most US states?
- 3 years from last visit
- 6 years from date of creation or last effective date (Correct answer)
- 10 years from date of creation
- Indefinitely
Correct 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.
Question 2: Which element is MOST critical to include when documenting a manual muscle test (MMT) result in an AK session?
- Patient's insurance policy number
- Specific muscle tested, grade assigned, and side (left/right) (Correct answer)
- Practitioner's license renewal date
- Room temperature at time of testing
Correct 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.
Question 3: A patient requests a copy of their AK records. Under HIPAA, the practitioner must typically provide access within:
- 7 calendar days
- 30 days, with one 30-day extension if needed (Correct answer)
- 60 days with no extension
- 90 days
Correct 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.
Question 4: When recording a therapy localization (TL) finding, the practitioner should document:
- Only the anatomical site that was touched
- The anatomical site, resulting change in muscle response, and clinical interpretation (Correct answer)
- The patient's subjective pain rating only
- The brand of supplement recommended
Correct 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.
Question 5: Which statement best describes the purpose of a problem-oriented medical record (POMR) in AK practice?
- It replaces the need for informed consent
- It organizes patient data around identified clinical problems to track progress systematically (Correct answer)
- It is used exclusively for insurance billing
- It documents only nutritional supplement protocols
Correct 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.
Question 6: An AK practitioner adds a late entry to a patient's chart two days after the visit. Best practice requires:
- Backdating the entry to match the visit date
- Labeling it clearly as a late entry with the current date and reason for delay (Correct answer)
- Erasing the original notes and rewriting them
- Obtaining a court order before adding late entries
Correct 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.
Question 7: What does the 'O' section of a SOAP note primarily contain in an AK context?
- The patient's chief complaint in their own words
- Objective findings such as MMT grades, postural analysis, and TL results (Correct answer)
- The practitioner's diagnosis and clinical reasoning
- The planned treatment for the next visit
Correct 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.
AK Documentation & Record Keeping 2
Under HIPAA, how long must an applied kinesiologist retain adult patient records in most US states?