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24 Cards in this Set

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THe massage activity and an analysis of the treatment session documented on the SOAP note
Activity and analysis information
Information that is to be kept private unless the client expressly permits you to share it
Confidentiality
A normal activity of daily life that is limited by muscular or connective tissue conditions
Functional linitation
A form that documents a client's contact information, health history, or informed consent for care
Intake form
A quwetion that focuses the client's attention to clarify or specify information and to recall missing or forgotten details
Leading question
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
Massage treatment record
Your visual, palpation. range-of-motion, and gait assessments of the client's body and soft tissues documented on the SOAP note
Objective information
A question that requires a descriptive answer instead of a one-word answer
Open-ended question
The section of the SOAP note including plans for future treatment and self-care recommendations
Plan information
Mutual trust in a relationship
Rapport
A method in which you reiterate the client's words to convey your comprehension or clarify a misunderstanding
Reflective listening
An acronym for Subjective, Objective, Activity and analysis, and Plan that refers to a format for documentation
SOAP
Verbal and written information clients share with you regarding their health documented in the SOAP note
Subjective information
A specific goal that is determined after theraputic massage treatment to clarify progress toward restoring functional limitations
Treatment goal
Concepts that should be incorporated in the first meeting/session
Formal introduction
Verbal communication
Disclosure of possible after effects
Things included in a formal introduction
Names
Handshake
Eye contact
Identifying statement
Things to remember in a humanistic view of your clients
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
Special situations in which client information can be shared
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
Reasons for documentation
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
Information to include in documentation
Contact information
Health history information
Informed consent
Information to include on the client history form
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
Visual observations to record on the objective section of the SOAP note
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
Palpation observations to record
Hypertonic muscles
Atrophied muscles
Abnormal skin temperatures
Guidelines for documenting to ensure validity and dependability of the records
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