Chapter 9 Consultation and Documentation

When should the practitioner obtain informed consent from the client?

1. At the end of the consultation, after adequate information has been exchanged. 2. When a treatment plan has been agreed on. 3. When there are changes in the course of treatment.

A thorough preliminary client assessment includes.

1. Client history 2. Client observation 3. Client examination

Client information can be obtained by.

1. Consulting with a doctor, 2. Personal history forms 3. Client interviews

List four sources of information used when formulating a treatment plan.

1. Intake and health history forms 2. Interview 3. Preliminary assessment 4. Formulate session goals and choose massage techniques and areas to focus on.

List four types of information that are kept in the client files.

1. Intake form (e.g., name, address, phone, e-mail address) 2. Health history form or medical history 3. Treatment plan and records 4. Informed consent, billing and financial info; and SOAP notes.

List four areas that a practitioner may include in a policy statement.

1. Missed or late appointments 2. Payment of fees 3. Sexual boundaries 4. Disclaimer that their services are not a medical treatment.

What can the practitioner do to maintain client confidentiality

1. Obtain a signed informed consent before proceeding with treatment 2. Do not divulge client info to any third party without first obtaining a release of info form signed by client 3. Store client files in a secured or locked fireproof cabinet 4. Protect electronic files with appropriate passwords and firewalls 5. Keep client files and appointment books out of view of others.

what are the four sections of a SOAP chart and what do they contain?

1. Subjective- inital interview, whatever client tells therapist 2. Objective- any info the therapist gathers from history taking, observations, interview, and assessment 3. Assessment- records what was done in session and changes in symptoms/ responses by client 4 Planning- record suggestions for future visits, self care activities or recommendations for client

List four topics of disclosure that the therapist must provide to obtain informed consent from the client.

1. The practitioner's credentials and qualifications 2. Description of services offered 3. Policies and procedures 4. Description of massage techniques to be employed and their projected effects and outcomes, including benefits and possible side effects.

List six topics that should be included as business policies.

1. Therapist work schedule, when he/she is available to take appointments. 2. Cancellation policy 3. Session length 4. Confidentially policy 5. Medical information release 6. Sexual boundary policy; Alternates; fees; late or missed appointments.

List three reasons to perform a preliminary assessment.

1. To determine which massage procedure to perform on a prospective client. 2. Whether it is advisable to refer the client to another health professional. 3. To determine contraindications

List five topics that should be included in the massage policies and procedures.

1. Types of services offered 2. Qualifications of therapist 3. Business policies 4. Fees 5. Session procedures

Seven things that the therapist can accomplish during consultation

1. establish open and effective communication and rapport with client. 2. Explain procedures and policies. 3. Determine the client needs and expectations. 4. Complete, review, and clarify information on the client intake and medical history forms. 5. Determine if the client is currently under the care of a physician (healthcare) 6. Determine if there are contraindications for the massage. 7. Determine if the client should be referred to another health practitioner.

Which four types of information does a practitioner record in a treatment record?

1. which treatments were given 2. what special products were used 3. reactions client had to this or previouls sessions 4. changes in clients condition

When making a first appointment with a prospective client, what three questions can be asked for screening

1.What is your main reason for making this appointment 2. What is your previous experience with massage 3. How did you find out about my service

Accurate records of a client's treatment help the therapist to.

Achieve better results

Downcast eyes, slouching shoulders, a bright smile, and fidgeting hands are all examples of?

Body language

Information gained from intake and medical history forms, answers to questions, and descriptions the client offers are the basis for the

Client history

To help disclose problems and physiologic basis for the client's complaints, an assessment includes _______,_______, and ______.

Client history, Observation, and Examination

For a consultation to be effective, there must be clear ___________ between the client and the practitioner.

Communication

All clients information should be considered

Confidential

A meeting between a prospective client and the practitioner, in which views are discussed and valuable information is exchanged?

Consultation

Noticing how clients hold their bodies, how they move, and how they react to questions or manipulative tests are part of

Observation

Noticing how the client holds his body and how he/she moves is called

Observation

Which of the following is not part of and initial consultation?

Review outcomes related to desired goals.

Work performed on a client is documented in the

SOAP notes

The process of clarifying the appropriateness of an appointment is called.

Screening

An outline that the practitioner can follow for giving treatments is called.

Treatment plan

The outline that a practitioner develops and follows when giving massage treatments is termed

Treatment plan

The two most effective ways for the practitioner to ask questions of the client?

Written and verbally

Various manipulative and verbal tests that help determine more precisely the tissues or conditions involved are part of the

examination/ assessment