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 documenting a functional movement assessment. Which measurement approach best supports evidence-based documentation?
Answer: Using validated, standardized tools with numeric scores
Using validated, standardized assessment tools with numeric scores ensures objectivity, reproducibility, and evidence-based documentation.
Which information must be included in every session note to meet COKO documentation standards?
Answer: Date, client identifier, services provided, and the practitioner's signature
Every session note must include the date, client identifier, description of services rendered, and the practitioner's signature or credentials.
A client discloses during a session that they are being physically abused at home. What is the kinesiologist's documentation obligation?
Answer: Document the disclosure and follow mandatory reporting obligations where applicable
Disclosures of abuse must be documented, and kinesiologists must follow Ontario's mandatory reporting laws where they apply (e.g., children or vulnerable persons).
When documenting exercise prescription, which component is LEAST relevant to include?
Answer: The kinesiologist's personal opinion of the client's effort
Personal opinions about client effort are subjective and unprofessional; documentation should focus on objective, measurable exercise prescription parameters.
A kinesiologist works in an interprofessional setting. When another regulated health professional requests a client's records, what step is required first?
Answer: Obtain written client consent authorizing the disclosure
Written client consent is required before sharing records with any other health professional, even in an interprofessional care setting.
Which of the following best describes 'informed consent' in the context of kinesiology documentation?
Answer: A process documenting that the client understands proposed services, risks, and alternatives
Informed consent is an ongoing process documented to confirm the client understands the nature, risks, benefits, and alternatives of proposed services.
A client's electronic health record system crashes and session notes are lost. What is the kinesiologist's professional responsibility?
Answer: Document the data loss, recreate notes to the best of ability with a notation explaining the circumstance
When records are lost, the kinesiologist should document the data loss event and reconstruct notes as accurately as possible with a clear notation of the circumstances.