Chapter 10 Treatment Planning – Flashcards

the process of providing written information regarding client care.

The primary reason is to gather information and then develop a treatment plan that seeks to fulfill client therapeutic goals. It is also a vital tool for communicating with other health care providers about client care. Check with state board to find if massage therapists in your state must be HIPAA-compliant. Systematically collecting and documenting client information sharpens the therapist's critical thinking skills. Another reason, Client records and legal evidence, which serves to protect the therapist by establishing professional accountability. Written communication decreases liability risks by verifying the info your client has shared with you and supports the treatment that the client received. Documentation also helps in supporting payment reimbursement, improving the quality of client care, and it demonstrates to the public that the therapist followed accepted standards of care. Many state licensing boards are mandating systematic collection and ongoing documentation, which may be used in peer review, licensing determinations and other legal proceedings. Finally, relying on memory is poor record keeping.

the process involved in evaluating or appraising a client's condition based on subjective reporting and objective findings.

Currently, the 2 most popular formats are the SOAP note and the APIE note. Two other formats are CARE and PPALM notes. SOAP notes are probably the most widely used and most complex documentation format. Used chiefly by the medical community, massage therapy is often a more simple form of health care with considerably fewer variables than physical or occupational therapy. The PPALM documentation format assessment domains are relevant to massage treatment planning.

S: Subjective O: Objective A: Assessment P: Plan Subjective section contains the client's experiences of his or her condition Objective section contains the therapist's visual and palpatory findings, as well as the results of any examinations or tests. Assessment section outlines the physician's diagnosis of the client's condition Plan portion contains the treatment plan as directed by the physician, including the type, duration and expected outcome or results. One criticism of this format is that it lacks flexibility and often focuses on one problem only.

A: Assessment P: Plan I: Implementation E: Evaluation Assessment section contains subjective data and objective data, as well as the physician's diagnosis. It addresses pre-treatment conclusions. Plan states what should be done today and in the near future. Written before the massage. Implementation contains the methods and techniques used during that day's session. Evaluation is the therapist's determination of treatment outcome to date. addresses post-treatment conclusions.

C: Condition of client A: Action Taken R: Response of client E: Evaluation

Any information learned from the client or the client's family and friends; this information includes most written information obtained on the intake form and information gathered during conversation. The info is referred to as subjective because the client cannot present information without personal bias, it is his or her perception or point of view.

measurable and quantitative and obtained by the therapist through empirical means (measurable and verifiable via the senses). Objective findings include the size and shape of a mole, whether the right shoulder is higher than the left shoulder, and whether the left knee is more swollen than the right knee and by how much. The main skills used for gathering objective information are observation and palpation.

outlines the activities and procedures that can be performed by members of a licensed profession. The scope of practice for massage therapists in your state often includes: - client assessment by health history and intake, interview, observation of posture and movement such as joint range of motion, palpation, and, with client permission, consultation with the other health care providers participating in a client's care. - formulation of an individualized treatment plan based on client assessment. - determination of whether massage therapy is indicated or contraindicated. - informing client regarding treatment and obtaining consent before initiating treatment - documenting a client's health history, intake interview, assessment findings, treatment protocols, and treatment outcomes - use of touch with or without pressure includes effleurage (gliding), petrissage (kneading), tapotement (percussion) lifting, compression, holding, vibration, friction, and pulling by use of digits, hands, forearms, elbows, knees or feet, and mechanical appliances that enhance massage therapy techniques. - use of lubricants such as oils, gels, lotions, and creams, as well as powders, liniments, ointments, antiseptics, rubbing alcohol and similar preparations. - application of therapeutic modalities and agents, which include hot and cold applications (such as compresses, ice or hot packs, stones and heat lamps), hydrotherapy, topical herbal agents, body wraps, topical application of sugars or salts for exfoliation and detoxification purposes, tools, electric massagers, essential oils, and application of tape for the purpose of therapeutic benefit that does not restrict joint movement. - use of joint mobilizations and stretching - energetic methods through the use of touch contact or noncontact techniques. - offering suggestions and recommendations of self-care and health maintenance activities, including but not limited to self-massage, self-administered hydrotherapy applications, movement and stretching activities, and stress reduction and stress-management such as structured breathing techniques, progressive relaxation, and meditation - the determination of whether referral to another health care provider is appropriate or necessary to address the client's condition when the care needed is beyond the therapist's scope of practice and training

permission for treatment given by a client after he or she has been informed of the risks, benefits, and consequences of the techniques and procedure(s). May be part of the client intake form.

documented process of planning a client's treatment or course of treatment. process takes into account: 1. the client's therapeutic goals or reasons for seeking massage therapy 2. his or her current health status 3. information gathered on a completed intake form 4. answers to questions asked by the therapist 5. palpation of tissues 6. assessment procedures such as for range of motion, gait, and posture. The resultant treatment plan, or plan of care, consists of strategies the therapist will use to resolve issues and address goals identified by the client.

Stay focused ... conversation is centered on your client's health and issues related to massage therapy. Look at your client more than the clipboard ... take notes sparingly by jotting down key words during the interview. Listen intently and signal your interests ... active listening is conveyed by eye contact and occasional nodding or using facial expressions that coincide wit the tone of the message. Use both open-ended and closed-ended questions ... open ended questions are broader in scope; close ended questions are narrower.

offer little restriction in answering and allow your client to reflect and clarify thoughts and feelings. Examples of open ended questions are: - What brings you to the clinic? - Tell me about your headache? - How can I help you be more comfortable? - Anything else?

more direct, usually requesting a factual or denial statement such as yes, no or the right shoulder. Examples of closed ended questions are: - Does it hurt to raise your right arm? - Does pain radiate down your left leg? - Can you take more pressure on this tender area? - Do you want me to spend more time on your right shoulder or your left?

PPALM is a method of obtaining and recording data relevant to client assessment and treatment planning. It features 5 assessement domains and encompass observable and palpable data: 1. Purpose of Session 2. Pain 3. Allergies and Skin Conditions 4. Lifestyle and Vocation 5. Medical Information

OPPQRST: Onset Provocative Palliative Quality Radiation Site Timing Answers to these questions will help you decide where to massage, if the area needs to be avoided, or to postpone massage.

Acute pain is an event; Chronic pain is a situation, state of existence

Palpation is touching with purpose and intent and is part of the premassage assessment, as well as ongoing during the session. In massage, the primary purpose of palpation is to locate treatment areas such as taut bands, spasms, and trigger points. However, palpation can also reveal other aspects of the client's health (i.e., swollen lymph nodes), which affect treatment (i.e., local or absolute contraindications).