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Chapter 9: Consulation and Documentation
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Chapter 9: Consulation and Documentation

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Questions and Answers

What should intake and health history forms include?

  • Information on how a court can subpena medical records
  • Information about the client's favorite hobbies
  • Missed or late appointments, payment of fees, and sexual boundaries
  • A consent paragraph stating that the client has given you all the information necessary to determine contraindications (correct)
  • When are body diagrams helpful?

  • When the client has some painful or stiff areas that require attention (correct)
  • When the client wants to learn anatomy
  • When the client has moles and acne on the body
  • When the client is unaware of where their pain is
  • What are the primary elements of assessment?

  • Proper communication
  • The client's payment information
  • Clients history and age
  • Client's History, observation, and examination (correct)
  • What does observation include?

    <p>Noticing how the client holds their bodies and how they move, how they react to questions or manipulative tests</p> Signup and view all the answers

    What is a treatment plan?

    <p>An outline the practitioner can follow when giving massage treatments</p> Signup and view all the answers

    What should the practitioner do in post-session interviews?

    <p>Determine what techniques and modalities were effective</p> Signup and view all the answers

    What is an educational process that ensures the client has received enough information to understand the nature and extent of the massage services

    <p>Informed Consent</p> Signup and view all the answers

    What will most software programs include for you?

    <p>Intake, medical history, and consent forms</p> Signup and view all the answers

    How should one make a correction on a handwritten record?

    <p>Put a single line through the error and then add the new information</p> Signup and view all the answers

    Speaking, listening, writing and body language are examples of what

    <p>Communication Skills</p> Signup and view all the answers

    What are ways to personalize the connection during the consultation

    <p>Maintain visual contact, using the client’s name, and listening attentively</p> Signup and view all the answers

    What is NOT a form of non-verbal communication?

    <p>Attitude</p> Signup and view all the answers

    Which behavior DOES NOT indicate discomfort during a massage?

    <p>Moaning</p> Signup and view all the answers

    What does active listening involve?

    <p>Summarizing what was said</p> Signup and view all the answers

    When should updates for clients be provided?

    <p>When there are new medications or diagnosis</p> Signup and view all the answers

    What should be discussed during the first consultation?

    <p>The policies and procedures</p> Signup and view all the answers

    Why is it important to inquire about what a client does in their free time?

    <p>To understand their lifestyle and potential stressors</p> Signup and view all the answers

    From history taking, observation, interview and assessment procedures, what type of information will the therapist gather?

    <p>Objective</p> Signup and view all the answers

    What are the two ways of asking questions?

    <p>Written and Verbal</p> Signup and view all the answers

    What do the operation and client interaction policies NOT cover

    <p>Treatment plan</p> Signup and view all the answers

    What should be discussed when talking about the types of services offered?

    <p>Modalities</p> Signup and view all the answers

    After the initial visit, the following visits should begin the session with what?

    <p>Short Question and Answer Period</p> Signup and view all the answers

    What should you state about the release of information shared during the session to the client?

    <p>All files are confidential except when subpoenaed by a court of law</p> Signup and view all the answers

    What is NOT a benefit of concise documentation?

    <p>Ability to track the client with the address book</p> Signup and view all the answers

    What is NOT a benefit of concise documentation?

    <p>List of other healthcare professionals for a dual-relationship</p> Signup and view all the answers

    Study Notes

    Communication Skills

    • Include speaking, listening, writing, and body language
    • Key aspects of effective communication in a massage therapy setting

    Personalizing the Connection

    • Maintain visual contact with the client during the consultation
    • Use the client's name to establish a personal connection
    • Listen attentively to the client's needs and concerns

    Non-Verbal Communication

    • Includes posture, gestures, and facial expressions
    • Important aspects of communication in a massage therapy setting

    Indications of Discomfort

    • Fidgeting, muscle contractions, and flinches during a massage may indicate discomfort
    • Require alterations to the massage technique to ensure client comfort

    Active Listening

    • Involves summarizing what the client has said and restating it to ensure understanding
    • Allows the client to agree or clarify their statements

    Follow-Up Visits

    • Should begin with a short question and answer period to determine any changes in conditions or course of treatments

    Policies and Procedures

    • Should be explained to the client during the first consultation
    • Cover missed or late appointments, payment of fees, and sexual boundaries

    Services Offered

    • Should be discussed in terms of modalities
    • Clearly explain the types of services offered to clients

    Confidentiality

    • All files are confidential except when subpoenaed by a court of law
    • Ensure clients understand the confidentiality of their information

    Asking Questions

    • Can be done verbally or in writing
    • Important for gathering information and understanding client needs

    Updates for Clients

    • Required for new medications or diagnoses
    • Ensure clients provide updated information to ensure safe and effective massage therapy

    Client Intake and Health History

    • Should include a consent paragraph stating that the client has provided all necessary information
    • Helps determine contraindications and ensure safe massage therapy

    Body Diagrams

    • Helpful when clients have painful or stiff areas requiring attention
    • Visual aid to identify areas of focus for massage therapy

    Assessment Elements

    • Include client history, observation, and examination
    • Key components of a thorough assessment in a massage therapy setting

    Observation

    • Includes noticing how clients hold their bodies and move
    • Noticing how clients react to questions or manipulative tests

    Treatment Plan

    • An outline for the practitioner to follow during massage treatments
    • Ensures a structured and effective approach to massage therapy

    Post-Session Interview

    • Allows for evaluating the client's massage experience and effectiveness of techniques and modalities
    • Helps practitioners refine their approach for future sessions
    • An educational process ensuring clients understand the nature and extent of massage services
    • Ensures clients are informed and consent to massage therapy

    Objective Information

    • Gathered through history taking, observation, interview, or assessment procedures
    • Helps practitioners develop a thorough understanding of clients' needs and conditions

    Software Programs

    • Typically include intake, medical history, and consent forms
    • Streamlines the administrative process for practitioners

    Handwritten Record Corrections

    • Make corrections by putting a single line through the error and adding the new information
    • Ensures accuracy and clarity in handwritten records

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    Description

    Test your knowledge on communication skills including speaking, listening, writing, and body language, as well as non-verbal cues like posture, gestures, and facial expressions. Explore ways to personalize connections during consultations and learn about indications of discomfort during a massage that may require altering the approach. Understand the concept of active listening and its importance in effective communication.

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