The process of providing written information regarding client care that a therapist needs to collect for many reasons is:
The treatment plan for a client serves as an organizational framework for a massage. The diagram that emcompasses all of the steps that the therapist takes is?
C. Client Web
What is the process involved in appraising a client's condition based on subjective reporting and objective findings, involving the clients goals and objectives for the session and determine the length and depth?
What is the therapist's strategy used to help the client achieve their goals, established once the assessment data is analyzed?
What is the outlined steps the therapist will follow, to provide a tailor-made session for each client, thereby improving professional services and open communication with other health care providers regarding how to serve the client?
B. Treatment Plan
What is the standard documentation method in the medical and paramedical fields?
D. SOAP Notes
What is a prescription is a written order by a physician or other qualified health care provider to a person properly authorized to dispense or perform the order which is usually for medication, therapy or a therapeutic device.
D. Prescriptive Directives
What is the collection of information learned from the client or the client's family and friends, including most written information obtained on the intake form and the clients personal preception.
C. Subjective Data
What is the collection of measurable and quantitative obtained by the therapist through emprical means (measurable and verifieable via the senses) such as the size of a mole, whether the right shoulder is higher than left or whether left knee is swollen?
C. Objective Data
What is the assessment method done through touching with purpose and intent, including locating muscle origin and insertion via tendons and bony markings noting differences between muscle tension and tone.
What does the acronynm SOAP mean?
S-Subjective, O-Objective, A-Assessment, P-Plan
What does the Acronym SOAPIER stand for?
S - Subjective
What does the Acronym APIE stand for?
P- Plan of Care
What is the client's authorization for professional services based on information that the massage therapist provides, permission for treatment and is a common principle in all health care fields?
D. Informed Consent
Part of an informed consent form, this section is the therapist's education skills, and abilities and will very among therapists.
C. Description of Modalities
Part of the client informed consent form, this section explains the effects that could happen durring a massage that may be negative such as blood clots, bruising, soreness.
C. Potential Risks and Side Effects
One of the sections of the Informed consent form, this means that the client has the right to terminate the session at anytime for any reason. It can also be for the therapist when a contraindication is suggested or presented, the therapist has a right, responsibility and even an obligation to refuse to treat the client or the local area involved.
C. Right of Refusal
What are Ten Tips for Documenting?
1. Therapist's name and signature, along with date of session
2. Maintain confidentiality
3. Use blue ink color
4. Correct errors with a single line and initials, avoiding correction fluid or tape
5. Use precise and correct medical terminology
6. If client misses appointment, document with an entry on their record such as no show or canceled, no reschedule.7. Be careful with abbreviations and use of symbols, avoiding jargon as this could be misinterpreted, such as SOB for Shortness of Breath
8. Write Legibly
9. Use sentence fragments to highlight the information gained from client, using direct quotes when applicable
10. Keep in mind of scope of practice, you can make observations, but cannot diagnose a disease.
What does the acronym PPALM stand for?
P - Purpose of Session / reason for wanting the massage
P - Pain and Discomfort / subjective reporting of the client's pain
A- Allergies -Skin conditions / questions, observations and palpations of skin temperature, disorders and allergies
L - Lifestyle / Factors that contribute to this domain are occupation, Leisure, Stress Level, Nutrition, Regular Exercise
M - Medical History / Medical information from client's past and the intake
What does the acronym OPPQRST stand for when reviewing pain and discomfort?
O - Onset / When did it start?
P - Provocative / What makes it worse?
P - Palliative / What makes it better?
Q - Quality / How would you describe the pain?
R - Radiation / Does the pain radiate?
S - Site / Where does it hurt
T - Timing / How often does it hurt?
What are Eight different types of medication that can effect a massage therapy?
1. Nonsteroidal Antiinflammatory Drugs (NSAIDS) - deep effleurage needs to be monitored for it can cause bruising while on these
2. Muscle Relaxers - same as Narcotic Analgesics
3. Narcotic Analgesics - Caution is merited for these depress sensory information enterning the nervous system
4. Corticosteroids - taking these, over a period of 30 days, results in loss of integrity of various body tissues
5. Antidepressents and antipsychotics - Same as Narcotic Analgesics
6. Anticoagulants and Platelet Inhibitors
7. Transdermal Patches
8. Injected Medications
What is a type of lengthy summarization of client progress spanning through numerous sessions and prescriptive periods.
A. Narrative Report
What is a summarization of client progress over an extended period, usually 30 days or the length of a prescriptive period, whichever comes first.
A. Progress Report
What is a term denoting information that is verifiable through the senses?
What are the ten parts of the Confirmed Consent form for a patient?
1. Therapist's credentials
2. Description of modalities
3. Expectations and potential benefits
4. Potential risks and possible underirable side effects
5. Statement of Scope of Practice
6. Right of Refusal
7. Professional and Ethical Responsibility
8. Information use
9. Office Policies
10. Authorization and Signature, date and confirmation of client and therapist