CMP Documentation Standards 5 — Questions and Answers
Question 1: What does a signed informed consent form in a client's file show?
- The client understood the treatment, its benefits and risks, and agreed to it (Correct answer)
- The client has paid in full
- The client was referred by a physician
- The therapist has liability insurance
Correct answer: The client understood the treatment, its benefits and risks, and agreed to it
Informed consent documents that the client agreed to treatment after it was explained to them.
Question 2: Which body-chart notation is commonly used to mark a trigger point on a SOAP diagram?
- Only a written paragraph with no symbol
- An X or a TP symbol at the location (Correct answer)
- A smiley face
- A dollar sign
Correct answer: An X or a TP symbol at the location
Body diagrams use a standard key of symbols, such as X or TP for trigger points, so findings can be recorded quickly and consistently.
Question 3: A physician has referred a client for massage. Why should the therapist keep the referral or prescription on file?
- It replaces the intake form
- It is decorative
- It allows the therapist to diagnose
- It documents medical oversight and may be required for insurance reimbursement (Correct answer)
Correct answer: It documents medical oversight and may be required for insurance reimbursement
A referral supports insurance claims and shows the treatment was coordinated with the client's physician.
Question 4: During a session, a client tells the therapist about thoughts of self-harm. Besides referring the client appropriately, what documentation is required?
- A personal opinion of the client's mental state
- None, since it was a private conversation
- An objective, factual note of what the client said and what the therapist did, such as the referral (Correct answer)
- A diagnosis of depression
Correct answer: An objective, factual note of what the client said and what the therapist did, such as the referral
Record what was said and what action was taken in factual terms, without making a diagnosis.
Question 5: Which entry correctly uses common documentation abbreviations?
- 'ROM' for 'room number'
- 'c/o' for 'care of the office'
- 'bilat' for 'billing later'
- 'c/o' for 'complains of' and 'bilat' for 'bilateral' (Correct answer)
Correct answer: 'c/o' for 'complains of' and 'bilat' for 'bilateral'
Standard abbreviations such as c/o (complains of) and bilat (bilateral) are widely understood in healthcare notes.
Question 6: Why is consistent and thorough documentation important if a client files a complaint against a therapist?
- It does not matter legally
- It serves as evidence of the care provided and the client's consent (Correct answer)
- It replaces liability insurance
- It guarantees the therapist wins
Correct answer: It serves as evidence of the care provided and the client's consent
Accurate records are the therapist's main evidence of what happened and what was agreed to; in legal practice, 'if it wasn't documented, it wasn't done.'
Question 7: A therapist working in a spa writes only 'Swedish, 60 min, full body' for every client. What is the main problem with this approach?
- The notes are too long
- They leave out client-specific findings, responses, and contraindication checks needed for continuity of care (Correct answer)
- They break draping laws
- They are too detailed for insurance
Correct answer: They leave out client-specific findings, responses, and contraindication checks needed for continuity of care
Identical generic notes do not show individual assessment or response, which weakens continuity of care and legal protection.
