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 (A)</p> Signup and view all the answers

What is a treatment plan?

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

What should the practitioner do in post-session interviews?

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

What will most software programs include for you?

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

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

<p>Communication Skills (D)</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 (B)</p> Signup and view all the answers

What is NOT a form of non-verbal communication?

<p>Attitude (C)</p> Signup and view all the answers

Which behavior DOES NOT indicate discomfort during a massage?

<p>Moaning (B)</p> Signup and view all the answers

What does active listening involve?

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

When should updates for clients be provided?

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

What should be discussed during the first consultation?

<p>The policies and procedures (B)</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 (B)</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 (C)</p> Signup and view all the answers

What are the two ways of asking questions?

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

What do the operation and client interaction policies NOT cover

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

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

<p>Modalities (B)</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 (C)</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 (D)</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 (D)</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 (B)</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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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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