Requirements For Client Health Records Flashcards
1
Q
True or false, a health record is required for each client?
A
True
2
Q
The record must contain:
1. The clients ______ and _______
A
Name; address
3
Q
- The ______, _______, _______ of each of the client’s visit to the RMT
A
Date, time and duration
4
Q
- The _______ and _______ of the primary care physician
A
Name and address
5
Q
- Any relevant medical _______ and a history of massage therapy
A
History
6
Q
- Information on every ________ performed by the RMT and every _____ finding and _______ made by the RMT
A
Examination, clinical, assessment
7
Q
- Details of all ____ given by the RMT
A
8
Q
- Information on every ________of the client by the RMT to another health professional
A
Referral
9
Q
Details of every _____ or other amount _______ by the RMT
A
Fee charged
10
Q
10 A copy of every written ______
A
Consent
11
Q
- A copy of every _____ assessment
A
Needs
12
Q
- A copy of any ________ plan
A
Treatment
13
Q
- details of the treatment applied at each of the client’s visits by the RMT and the name of the RMT who applied the treatment.
A
14
Q
Client health records must be retained for 10 years after the client’s last visit, or 10 years after the day the client turned 18 (if they were under 18 at the time of their visit)
A
