Spa Vargas University MT101 Introduction to Massage Therapy

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Introduction Effective Communication and Interviewing Skills Documentation SOAP Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Effective Communication and Interviewing Skills Rapport attributes Good communication Making certain assumptions Using reflective listening skills Asking open-ended and leading questions Looking past verbal report for nonverbal information Adherence to confidentiality Letting clients know what to expect in the therapy session Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Establishing Rapport Formal introduction Confident, caring handshake Maintain eye contact Using client’s name Verbal communication Announce technique changes Offer client a safety mechanism Disclosure Let clients know what to expect post-massage Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Confidentiality Clients’ information should be kept private Sharing clients’ records Client must supply written authorization Examples: Client includes you as part of the health care team Insurance company reimbursements Adhering to court order Special social care situations (abuse, threats of harm) Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Certain Assumptions Each client is unique (individual story) Each client has skills Each client interacts with the environment, has a life outside of the massage treatment room Clients are like us (treat as equals) Clients are honest: ask the right questions to get the best information Each client sincerely desires success, even without total adherence to self- care Client shares responsibility to give pertinent information during interview Each client desires interaction and negotiation; give client a chance to ask questions Each client knows what the problem is, has true story Each client recognizes success Client’s definition of success may be different from yours Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Reflective Listening and Questions Reflective listening Repeat or reiterate the client’s words to convey comprehension Ask clarifying questions to determine whether you understood the client Open-ended questions Require a descriptive answer Elicit as much information as possible Broaden interview beyond yes-or-no answers Leading questions Focus the client’s attention to clarify or to give more specific information and recall forgotten details Refocus conversation on main complaint Can help determine plan for treatment Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Non-verbal Communication Tone of voice Breathing patterns Body language Facial expressions Eye contact Areas of muscular tension Body positioning Emotional clues Most often reinforces verbal information, sometimes contradicts Nonverbal cues can offer information about client’s stress levels and healing or recovery time Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Documentation Creates and maintains client’s record Used to develop initial and subsequent treatment plans Can also be used for communication between health care professionals May become legally required as massage becomes more involved in health care Insurance companies may require for reimbursement Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Reason for Documentation Check for contraindications Know which techniques are effective Track client’s self-care activities Proof of progress toward goals Promote professional image and trust with client Convey importance of health history Insurance companies Coordinate care with other health care practitioners Protection in the event of malpractice lawsuit Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Documentation Forms Contact information Health history Informed consent for care Subjective ideas from clients about how they feel and what they want to accomplish Objective evaluations from therapist about client Massage treatment record Client input Objective assessments Massage techniques Results of treatment session Plans for future treatment sessions Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation S.O.A.P. Common format for documenting massage sessions Subjective information supplied by client Objective information observed by therapist Activity and analysis: what was done and the result Plan for future treatment and self-care recommendations Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Subjective Information Written and oral information from client Client history Personal identification and contact information Current health information Health concerns Goals for health and treatment Health history Consent for care and consent to share information with other healthcare providers Interview Chance to sort through the information Leading questions are useful in clarifying client’s input Areas covered by interview: General Circulatory Musculoskeletal Neurological Psychosocial Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Functional Stress Assessment Health conditions Accidents and surgeries Age considerations Lifestyle Postural factors Nutrition and medication Emotional and psychological factors Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Objective Information Massage therapist’s assessment of client Visual observations Areas of swelling or inflammation Unevenness of bilateral bony landmarks or muscles Postural abnormalities Compensation patterns Gait (walking) assessments Localized areas of abnormal skin coloration Palpation observations Hypertonic or atrophied muscles Abnormal skin temperatures Range of motion evaluation Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Activity and Analysis Data covers the massage activity and analysis of the session Activity includes: Techniques client liked or disliked Effective versus ineffective techniques Changes made to the massage or flow of the massage Analysis includes: Post-treatment assessment Prioritized list of functional limitations Set of treatment goals Clarifies progress Recognizes when goals are met Goals should be reasonable Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Plan Information Future treatment plans Frequency of future treatments Duration of treatments Techniques to try and techniques to avoid Long-term goals achieve within eight to nine months Recommendations for self-care Clients have to buy into recommendations Redirect client’s focus from illness and pain to health and absence of pain Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation S.O.A.P. Guidelines Information pertinent to client’s main concern or massage treatment Clear but brief Standard abbreviations Use pen, not pencil Strike through mistakes and write initial and date near the line Neat and legible Keep in safe, private place Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Copyright © 2010 Spa Vargas University

Spa Vargas University MT101 Introduction to Massage Therapy Chapter 5: Communication and Documentation Summary Effective communication gathers appropriate and important information Client-focused interview gets the best information SOAP chart organizes information into a usable format Documentation is essential for safe and effective treatment of clients and for communication with other healthcare providers Copyright © 2010 Spa Vargas University