CMP Documentation Standards 5

Question 1

What does a signed informed consent form in a client's file show?

Accepted Answer

The client understood the treatment, its benefits and risks, and agreed to it

Answer

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?

Accepted Answer

An X or a TP symbol at the location

Answer

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?

Accepted Answer

It documents medical oversight and may be required for insurance reimbursement

Answer

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?

Accepted Answer

An objective, factual note of what the client said and what the therapist did, such as the referral

Answer

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?

Accepted Answer

'c/o' for 'complains of' and 'bilat' for 'bilateral'

Answer

Standard abbreviations such as c/o (complains of) and bilat (bilateral) are widely understood in healthcare notes.

CMP - Certified Massage Practitioner Practice Test

CMP - Certified Massage Practitioner Practice Test

CMP Documentation Standards 5