MMT Clinical Documentation 3 — Questions and Answers
Question 1: A therapist is documenting MMT for a patient post-CVA with spasticity. Which notation should be added to the standard grade to reflect this confounding factor?
- An asterisk (*) with a note explaining spasticity (Correct answer)
- A plus (+) modifier to indicate increased tone
- No modification; spasticity is irrelevant to MMT grading
- A grade of NT (not testable) must always be used
Correct answer: An asterisk (*) with a note explaining spasticity
An asterisk or footnote is used to flag that spasticity or other confounding factors may affect the validity of the MMT grade.
Question 2: What does 'NT' mean in MMT documentation?
- Normal Tone
- Not Tested (Correct answer)
- Nerve Tension
- Near Threshold
Correct answer: Not Tested
'NT' stands for Not Tested and is used when MMT could not be performed due to pain, cast, wound, or other contraindication.
Question 3: In SOAP note format, where would a therapist record MMT numerical grades obtained during a session?
- Subjective section
- Objective section (Correct answer)
- Assessment section
- Plan section
Correct answer: Objective section
MMT grades are objective, measurable data and belong in the Objective (O) section of a SOAP note.
Question 4: A therapist documents 'wrist extensors 3+/5.' Which finding does this reflect?
- Full ROM gravity-eliminated with moderate resistance
- Full ROM against gravity with minimal added resistance tolerated (Correct answer)
- Partial ROM against gravity, no resistance
- Full ROM against gravity and strong resistance
Correct answer: Full ROM against gravity with minimal added resistance tolerated
Grade 3+ indicates full ROM against gravity with the ability to tolerate only minimal added resistance before yielding.
Question 5: Which element is NOT required in a legally defensible MMT documentation entry?
- Muscle or muscle group tested
- Side tested (right or left)
- The brand of dynamometer used (Correct answer)
- Date of assessment
Correct answer: The brand of dynamometer used
The brand of dynamometer is not required; what matters is the muscle tested, laterality, grade, date, and clinician signature.
Question 6: A therapist writes: 'Quadriceps strength: 3/5 bilaterally — patient unable to tolerate resistance due to pain.' What documentation principle does this exemplify?
- Using the lowest possible grade to be conservative
- Contextualizing the grade with a clinical qualifier (Correct answer)
- Inflating the score to justify continued therapy
- Avoiding objective data in favor of subjective reports
Correct answer: Contextualizing the grade with a clinical qualifier
Adding a qualifier explains that the grade may not fully represent volitional strength, improving clinical validity of the documentation.
Question 7: When documenting serial MMT assessments to demonstrate progress, which comparison is most clinically meaningful?
- Today's grade vs. a published normative value
- Today's grade vs. the contralateral limb only
- Today's grade vs. the patient's own baseline grade from initial evaluation (Correct answer)
- Today's grade vs. the average for the patient's age group
Correct answer: Today's grade vs. the patient's own baseline grade from initial evaluation
Comparing to the patient's own baseline is the most meaningful way to document functional progress over the course of treatment.
MMT Clinical Documentation 3
A therapist is documenting MMT for a patient post-CVA with spasticity.
Which notation should be added to the standard grade to reflect this confounding factor?