Documentation Standards Flashcards
7 cards from real LMT 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 Standards flashcards as text
How long should massage therapy client records be retained?
Answer: According to state law and regulations, often several years
Retention periods vary by state; many require keeping records for several years after the last visit.
What is the proper way to dispose of old client records once the retention period has passed?
Answer: Shred or securely destroy them
Secure destruction such as shredding protects client confidentiality.
A client becomes faint during a session. Which documentation is most appropriate?
Answer: Record the incident, time, actions taken, and client's condition at departure
Incidents should be documented factually and completely, including the response.
Which tool lets a client visually mark areas of pain or tension on the intake form?
Answer: Body diagram or figure chart
Body diagrams let clients and therapists mark the location of symptoms.
Under HIPAA, the 'minimum necessary' standard means:
Answer: Only the least amount of PHI needed for a purpose should be used or disclosed
The minimum necessary rule limits PHI use and disclosure to what is needed for the task.
Which is an example of a breach of client confidentiality?
Answer: Posting a client's photo and treatment story on social media without consent
Sharing identifiable client information publicly without consent violates confidentiality.
Why is thorough documentation important when a massage therapist works with a client's physician?
Answer: It communicates progress and supports coordinated care
Clear records support communication and continuity of care among providers.