American Massage Therapy Association (AMTA) Practice Test

Which of the following is not true of record-keeping?

1. Records should be written in ink or produced as an electronic format

2. A therapist should use only widely-accepted abbreviations

3. A therapist is free to use any shorthand that makes the most sense to them

4. Each page of the record should identify the patient by name and by clinic or record number

The correct answer is: A therapist is free to use any shorthand that makes the most sense to them

The correct interpretation of the statement concerning record-keeping is that it emphasizes the importance of clarity and professionalism in maintaining client records. Using only widely accepted abbreviations and ensuring that records are clear and legible are critical components of effective documentation practices. Clarity in record-keeping not only serves the therapist for future reference but is also vital for other healthcare providers who may need to access the records. Established standards for abbreviations help avoid confusion or misinterpretation of information, which could lead to errors in patient care. Furthermore, including identifying information such as the patient’s name and clinic or record number on each page supports continuity of care and facilitates easier access to records. In contrast, relying on personal shorthand can introduce inconsistencies and create barriers to understanding the records. It may not be interpretable by others or even by the therapist at a later time, undermining the integrity of the documentation process. Therefore, the idea of using any shorthand a therapist prefers is not aligned with best practices in record-keeping and is the aspect that is not true.