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Chapter 9: Consulation and Documentation

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25 Questions

What should intake and health history forms include?

A consent paragraph stating that the client has given you all the information necessary to determine contraindications

When are body diagrams helpful?

When the client has some painful or stiff areas that require attention

What are the primary elements of assessment?

Client's History, observation, and examination

What does observation include?

Noticing how the client holds their bodies and how they move, how they react to questions or manipulative tests

What is a treatment plan?

An outline the practitioner can follow when giving massage treatments

What should the practitioner do in post-session interviews?

Determine what techniques and modalities were effective

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

Informed Consent

What will most software programs include for you?

Intake, medical history, and consent forms

How should one make a correction on a handwritten record?

Put a single line through the error and then add the new information

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

Communication Skills

What are ways to personalize the connection during the consultation

Maintain visual contact, using the client’s name, and listening attentively

What is NOT a form of non-verbal communication?


Which behavior DOES NOT indicate discomfort during a massage?


What does active listening involve?

Summarizing what was said

When should updates for clients be provided?

When there are new medications or diagnosis

What should be discussed during the first consultation?

The policies and procedures

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

To understand their lifestyle and potential stressors

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


What are the two ways of asking questions?

Written and Verbal

What do the operation and client interaction policies NOT cover

Treatment plan

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


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

Short Question and Answer Period

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

All files are confidential except when subpoenaed by a court of law

What is NOT a benefit of concise documentation?

Ability to track the client with the address book

What is NOT a benefit of concise documentation?

List of other healthcare professionals for a dual-relationship

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


  • 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


  • 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

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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