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24 Cards in this Set
- Front
- Back
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THe massage activity and an analysis of the treatment session documented on the SOAP note
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Activity and analysis information
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Information that is to be kept private unless the client expressly permits you to share it
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Confidentiality
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A normal activity of daily life that is limited by muscular or connective tissue conditions
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Functional linitation
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A form that documents a client's contact information, health history, or informed consent for care
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Intake form
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A quwetion that focuses the client's attention to clarify or specify information and to recall missing or forgotten details
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Leading question
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The document containing input from clients, your objective assessments of the clients' condition, the massage techniques you use, results of the treatment session, and plans for future massage treatment
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Massage treatment record
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Your visual, palpation. range-of-motion, and gait assessments of the client's body and soft tissues documented on the SOAP note
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Objective information
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A question that requires a descriptive answer instead of a one-word answer
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Open-ended question
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The section of the SOAP note including plans for future treatment and self-care recommendations
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Plan information
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Mutual trust in a relationship
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Rapport
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A method in which you reiterate the client's words to convey your comprehension or clarify a misunderstanding
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Reflective listening
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An acronym for Subjective, Objective, Activity and analysis, and Plan that refers to a format for documentation
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SOAP
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Verbal and written information clients share with you regarding their health documented in the SOAP note
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Subjective information
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A specific goal that is determined after theraputic massage treatment to clarify progress toward restoring functional limitations
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Treatment goal
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Concepts that should be incorporated in the first meeting/session
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Formal introduction
Verbal communication Disclosure of possible after effects |
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Things included in a formal introduction
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Names
Handshake Eye contact Identifying statement |
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Things to remember in a humanistic view of your clients
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Each client is unique
Each client has skills Each client interacts with the environment Clients are like us Clients are honest (mostly) Each client sincerely desires success Each client shares responsibility with you during the interview Each client desires interaction and negotiation Each client knows what the problem is Each client knows when success has occured |
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Special situations in which client information can be shared
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Therapist is part of a healthcare team
Insurance company requires session information for reimbursement Court order for client information Client has given express written consent |
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Reasons for documentation
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Ensure that there are no contraindications
Record of which techniques were effective Encourage client participation by inquiring about self-care activities Written proof to illustrate progress toward goals You don't have to try to remember Written recods to share with insurance companies, healthcare practitioners, and to proctect yourself in case of lawsuit |
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Information to include in documentation
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Contact information
Health history information Informed consent |
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Information to include on the client history form
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Contact information
Current health information Health concerns Goals for health Goals for treatment History of injuries, illnesses, and surgeries Consent to exchange health information with other healthcare providers Consent for care |
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Visual observations to record on the objective section of the SOAP note
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Areas of swelling or inflamation
Unevenness of bilateral bony landmarks or muscles Postural abnormalities Compenstion patterns Gait assessments Localized areas of abnormal skin coloration especially redness |
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Palpation observations to record
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Hypertonic muscles
Atrophied muscles Abnormal skin temperatures |
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Guidelines for documenting to ensure validity and dependability of the records
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Information should be pertinent
Information should be clear but brief Abbreviations should be generally accepted industry standards Use pen Correct mistakes with a single line through and initials Should be neat and legible Kept in a safe place away from public access |
