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Chapter 6 / Communication and Documentation 261
examples above, roots are followed with an (o), which is
the most common combining vowel. For example, the root
“electr” means electricity, the root “cardi” means heart,
and “gram” means record. Compare the pronunciation of
“electrcardigram” to “electrocardiogram” to see the benefit
of combining vowels.
Translating Terms
The three word elements—prefix, root, and suffix—are the
building blocks for medical terminology. Once you understand how each word element works, it becomes easy to figure out what a word means. Not all medical terms have a
prefix, root, and suffix; some have only two of the elements
while others have two roots and a suffix.
Terms can be translated in five methodical steps. The
first step in translating medical terms is breaking up the term
into its word elements. The second step is defining the suffix,
particularly because suffixes indicate how the term is used.
Third, go to the beginning of the term and define the elements in order. String all the definitions together and check
the translation against a medical dictionary. Translation of
the word “fibromyalgia” can be done as follows:
1. Break up the word into its elements.
Fibromyalgia ⫽ “fibro” “my” “algia”
2. Start with the definition of the suffix.
“-algia” ⫽ painful condition of
3. Go to the beginning of the word and define each element.
“fibro” ⫽ fibrous
“my” ⫽ muscle
4. String the definitions together.
painful condition of fibrous muscle
5. Check your definition against a medical dictionary or
other source.
“painful condition of muscles, tendons, and joints”
Another example is the translation of “hypertonic”:
1. “hyper” “ton” “ic”
2. “ic” ⫽ pertaining to
3. “hyper” ⫽ excessive
“ton” ⫽ tone
4. pertaining to ⫹ excessive ⫹ tone
5. excessive tone in the muscles or excessive salt concentration in solution
One more example is the translation of “osteoarthritis”:
1. “osteo” “arthr” “itis”
2. “itis” ⫽ inflammation of
3. “osteo” ⫽ bone
“arthr” ⫽ joint
4. inflammation of ⫹ bone ⫹ joint
5. inflammation of the joints, especially the weightbearing joints, characterized by degenerative condition
of the articular cartilage
Some of the word elements that are used more
commonly in massage therapy include
• Prefixes: dys-, hyper-, hypo-, pre-, post-
• Roots: my(o), vertebr(o), cervic(o), fibr(o)
• Suffixes: -al, -algia, -itis
See Table 6-4 for some translations of terms used in the
field of massage therapy.
The process of translating terms is straightforward, but
you may need practice to become proficient. Medical dictionaries contain thousands of terms and by learning the
meanings of some of the more commonly used prefixes,
roots, and suffixes, you will not need to look up as many
medical terms for their definitions.
Spelling and Pronunciation
Proper translation and communication requires proper spelling
and pronunciation. Because of the Greek and Latin derivation
of so many medical terms, their spelling and pronunciation may
seem strange and unfamiliar, and regional accents can make
familiar words sound unfamiliar. Slight differences in spelling
can lead to very different meanings as well. For example, the
word “ilium” is a bone of the pelvis, and the word “ileum” is a
part of the digestive tract. These completely different anatomical structures have the same pronunciation, so context is important. Correct spelling must also be used in documentation to
keep accurate and useful records. Again, a medical dictionary
is an indispensable tool for every massage therapist. Table 6-5
provides some general tips for pronouncing medical terms.
Effective communication with clients is essential for
obtaining accurate and pertinent data for the initial and
subsequent massage treatment sessions. Before meeting
with a client, focus your attention on the appointment
and do your best to leave personal distractions out of the
treatment room. Be fully aware of your clients and their
262 INTRODUCTION TO MASSAGE THERAPY
WORD PREFIX ROOT SUFFIX DEFINITION (SPECIFIC REFERENCE
TO MASSAGE)
antagonist ant- (against) agon (struggle) -ist
(concerned with)
atrophy a-
(without, not)
biceps brachii bi- (two) ceps (head)
circumduction circum-
(around)
contraindication contra-
(against)
extension ex-
(away from)
fibromyalgia fibro (fiber)
hypertonic hyper-
(excessive)
infraspinatus infra- (below) spin (spine) -atus (refers to) refers to below the spine (specific
troph (growth) -y (condition of) (condition of muscular deterioration
-i (plural) two heads (specific arm muscle with
brachi (arm)
duct (to lead) -tion (action of) lead all the way around (circular
indicate (to
point)
ten (tendon) -sion (action of) action of away from the tendon
my (muscle)
ton (tone) -ic (pertaining to) condition of excessive tone (muscle
-tion (action of) indicating the other way (a situation in
-algia (painful
condition of)
one that works against (a muscle with
an opposing action)
or no growth)
two origins)
movement of a body part through its
range of motion)
which treatment is inappropriate)
(movement that opens the angle at a
joint and stretches the tendon)
pain in fibers and muscles (condition
with pain in muscles, tendons and
joints)
that is too tense)
muscle that originates below the
spine of the scapula)
isometric iso- (equal) metr (measure) -ic (pertaining to) pertaining to equal measure (muscle
activity in which antagonists work
equally and no movement occurs)
neuralgia neur (nerve) -algia (painful
condition of)
osteoarthritis oste (bone)
arthr (joint)
proprioception proprius
(your own)
cep (take)
tendinitis tendin (tendon) -itis
needs. Engaging the client in a good conversation helps
you gather the necessary information to provide safe and
effective treatment. A genuine interest in the client helps
the client feel heard and understood, leading to a more
trusting relationship. This is important for assisting the
-itis
(inflammation of)
-tion (action of) action of taking your own (ability to
(inflammation of)
client throughout the healing process and helps clients
cultivate a broader understanding of health. Always keep
clients and their needs at the center of the treatment
process to establish and support a safe, trusting, effective
relationship.
nerve pain (condition of pain along the
nerves)
inflammation of bone and joint
(condition of inflamed and
degenerative joints)
sense stimuli from your own body’s
position in space)
inflammation of tendons
Chapter 6 / Communication and Documentation 263
LETTERS COMMONLY PRONOUNCED EXAMPLE
c (before e, i, y) S quadriceps (KWAH-drih-seps)
c (before all other letters) K contraction (kon-TRAK-shun)
ch K cholesterol (koh-LESS-ter-ahl)
es (at the end of a word) EEZ meninges (meh-NIN-jeez)
eu OO
YOO
g (before e, i, y) J gemellus (juh-MELL-us)
g (before all other letters) G (hard sound) gluteus (GLOO-tee-us)
gm M diaphragm (DAHY-uh-fram)
gn N benign (bee-NAHYN)
i (at the end of a word) AHY nuclei (NOOK-lee-ahy)
pn N pneumonia (noo-MOHN-yuh)
ps S psoas (SOH-az)
pt T pterygoid (TAIR-ih-goyd)
x Z xyphoid (ZAHY-foyd)
Effective Communication and Interviewing Skills
There are several factors in effective communication skills
and the interview process. These include establishing rapport
(rah-POR), or mutual trust, through communication, making
certain assumptions about the client, using reflective listening
skills, asking open-ended and leading questions, and looking
beyond the client’s verbal report for nonverbal information.
The saying goes, “You never get a second chance to
make a first impression.” First impressions are lasting ones.
It is important to present and maintain a professional atmosphere from the beginning of the therapist–client relationship. The first meeting with a client is critically important, as
it provides the foundation for the professional relationship,
so the following actions should always be incorporated:
• Formal introductions that include names, a handshake, eye contact, and a statement that clearly identifies the therapist
• Verbal communication that gives the client control
over the treatment. For example, a therapist may
indicate when a change to a deeper or more invasive
technique will occur. You should offer a safety mechanism that allows clients to inform you if they are
uncomfortable in any way, which gives them permission to request that a particular technique be altered
or stopped.
• Disclosure of some of the effects of the session that
could develop in the next few days, especially if the
client was not familiar with the techniques used.
Establishing rapport is perhaps the single most important skill a massage therapist must have for the interviewing process.
a client is to offer a confident, caring handshake and a
greeting using the person’s first name. Know the correct
pronunciation and spelling of the client’s name, and nickname, if they prefer. One of the keys to establishing rapport is maintaining eye contact. Look clients in the eye
while discussing the details of their condition and history to communicate your interest in their explanation.
This also increases the client’s feelings of validation and
aponeurosis (AP-oh-noo-ROH-sis)
eustachian tube (yoo-STAY-shun
toob)
The first step to establishing rapport with
264 INTRODUCTION TO MASSAGE THERAPY
positive attention. Another technique for creating rapport
is to establish and continue to build trust by acknowledging the client’s input and maintaining confidentiality.
Phrases such as “I hear you” or “I understand” show that
you are paying attention to what the client said, again
offering validation.
Another factor in creating and building trust and rapport in the therapist–client relationship is confidentiality .
Any information the client provides should remain confidential, meaning that the information is to be kept private
and not shared with anyone else unless the client expressly
permits it. There are special situations when information in
client files is shared. The client may choose to use you as
part of a healthcare team, which could require you to share
session information with the other healthcare practitioners.
Insurance companies sometimes request session information to reimburse you or your clients. Client information
may be released to an attorney or judge upon court order
as part of litigation, as in auto accident cases. For you to
release the client’s records, the client must authorize and
sign a release form (Fig. 6-1). There are a number of occupations, including licensed massage therapy, that legally
require reporting abusive situations and threats of deadly
harm to the appropriate authorities, such as the police or
other governmental agency that protects children and families. You can inform clients of this possibility when you get
informed consent for care.
Clients who sense their importance to you are more
likely to trust you and, as a result, provide more pertinent
information. Another way to establish rapport is to explain
to clients exactly what they can expect to have happen in the
therapy session. Knowing what to expect takes the mystery
out of the process and makes clients more comfortable.
Certain assumptions about clients support the communication process by making sure you use a humanistic view
of your clients instead of a clinical, unfeeling approach:
• Each client is unique: The extent to which you
consider the individual story of each client directly
affects the client’s chances for improvement.
• Each client has skills: Communicating your recognition of the client’s skills and using those skills as a
personal strength enhances information gathering.
• Each client interacts with the environment:
Recognizing that clients are significantly affected by
their lives outside the massage therapy treatment
area and gathering more information about their
lives leads to more pertinent communication.
• Clients are like us: Considering clients as equal
human beings, with similar reactions and difficulties,
and maintaining equal footing with clients instead
of creating a dependent relationship, facilitates the
healing process.
• Clients are honest: Typically, clients give the best
information they can, but it is up to you to ask the
right questions to help them recall that information.
• Each client sincerely desires success: Clients do their
best to achieve their treatment goals. Sometimes
environmental factors prevent complete cooperation, and you must recognize these factors.
• Each client shares responsibility with you during the
interview: Although you are likely more experienced
with interviewing, clients also have a responsibility
to help the interview be successful.
• Each client desires interaction and negotiation: Most
clients attempt to understand your intent and evaluate your skills and knowledge by asking questions or
negotiating instructions.
• Each client knows what the problem is: Clients are
typically aware of factors contributing to their difficulties, and the therapist can learn these factors by
listening carefully.
• Each client knows when success has occurred: Clients
are often the best judges of whether treatment has
been successful, so recognize that their concepts of
success might be different from yours.
Although these assumptions are generalizations, they
will help you maintain a client-centered focus and will
support your work toward successfully reaching treatment
goals.
Reflective Listening
Good listening skills help you to further your rapport and
ensure that the information from the client is documented
accurately and completely. Maintaining a client-centered
focus throughout the interview process often requires the
skill of reflective listening. Reflective listening is a technique with which you repeat or reiterate the client’s words
to convey your comprehension or to clarify a misunderstanding. For example, a client may say, “The pain in my
shoulder gets worse after I sleep on my side all night.” You
may then respond to the client, “So when you sleep on one
side through the entire night, the pain in your right shoulder has increased by the time you wake up?” This question
determines if you have heard the client correctly and gives
the client an opportunity to clarify a misunderstanding.
Additionally, it helps you document the correct information.
As you gain more practice with the interviewing process
and use the fundamental skill of reflective listening, you will
become a more effective interviewer.
Open-ended Questions
Using your own style with reflective listening will help you
formulate questions to elicit as much information from
Chapter 6 / Communication and Documentation
265
Figure 6-1. Client records release forms. (A) Patient’s Release of Health Care Information.
266 INTRODUCTION TO MASSAGE THERAPY
Figure 6-1. (continued) (B) Authorization to Use and Disclose Health Information. (Reprinted with permission from Thompson DL.
Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 3rd ed. Baltimore: Lippincott Williams &
Wilkins, 2006.)
clients as possible regarding their present condition and
cumulative stressors that have affected it. The best method
of gathering information uses open-ended questions. Openended questions are those that require a descriptive answer
instead of a one-word answer. They encourage and broaden the conversation, often helping clients remember any
details they might have forgotten. For example, the closed
question, “Does your shoulder hurt today?” is likely to lead
to a short answer such as yes or no. In contrast, the openended question, “What makes your shoulder pain better or
worse?” may elicit a more thoughtful, thorough response
that provides more information about which soft tissues
B
Chapter 6 / Communication and Documentation 267
might be involved. Other examples of open-ended questions include:
• How would you describe your pain or discomfort?
• How did the pain or discomfort change during the
day?
• What kinds of activities made the pain or discomfort
more noticeable?
Leading Questions
After exploring open-ended questions, you might use leading
questions to refocus the conversation to the chief complaint.
Leading questions focus the client’s attention to clarify or to
give more specific types of information and to recall missing or forgotten details. For example, if a client’s chief complaint is right-sided neck pain, your reflective listening skills
and open-ended questions might evoke a story about a typical workday and a number of events that happened at work
last week that brought the client in for a massage. You can
ask leading questions regarding the neck pain to help you
understand which soft tissues might be involved:
• Is there any activity that you typically do with your
right side, such as carry your child or talk a lot on
the phone with the phone on your right side?
• Is there an activity where you turn your head mostly
to one side during a typical day?
• What position do you tend to sleep in?
• Can you show me the movements that hurt the
most?
These questions will help refocus the discussion to
determine the plan for the upcoming massage treatment.
Nonverbal Communication
Gathering information from clients involves more than just
collecting verbal data. Look beyond the client’s words written on the history form and the client’s answers from the
interview to gather the whole picture, paying attention to
nonverbal communication. These nonverbal cues help you
better understand how the clients perceive and manage their
conditions.
You can evaluate clients’ perceptions of their conditions by observing their tone of voice, breathing patterns,
and body language, including facial expression, eye contact, areas of muscular tension, and body positioning. Try
to notice anything that is out of the norm. A normal tone
of voice is recognized as steady instead of shaky, not too
loud or soft, not too rushed or hesitant, and not excessively
emotional. Body language can be especially helpful to massage therapists because people tend to accompany the verbal
description of the condition of their soft tissues with clues
for massage treatment. Sometimes clients will describe pain
or areas of restricted movement while they rub the affected
tissues a certain way, poke at themselves, hold their hand
over affected areas, or stretch restricted soft tissues. These
nonverbal messages can tell you which areas to include in
the session and which techniques to use. Body language is
not the only thing that indicates the techniques you should
use or that only certain techniques will work, nor does it
necessarily indicate the specific areas that are causing the
pain or restricted function, but it does suggest that these
techniques will be well received by the client and that those
tissues are most likely involved in the pain or restriction.
Sometimes the nonverbal communication reinforces
the spoken words, but many times, the nonverbal cues contradict the client’s words, and you have to recognize the
discrepancy to sort through the input and determine the
most effective approach to treatment. Consider a client who
comes in and briefly requests a massage just to relax and
denies any areas of pain or discomfort at the time. However,
the client’s words are quiet and shaky, there is no eye contact, and the client is slumped in the chair and breathing shallowly. While filling out the intake form, the client
rubs his or her temples, squeezes the eyes shut from time
to time, sits up straight a couple of times to hyperextend
and laterally flex, and rubs the posterior aspect of the neck.
The nonverbal body language suggests pain and some muscular tension in the head or neck. It also suggests that the
client might respond well to massaging the posterior and
lateral soft tissues of the neck and lateral flexion stretches
to theneck.
Clients’ nonverbal and emotional cues can also offer
information about their stress levels and healing or recovery
time. Generally, the higher the client’s stress level, the more
symptoms he or she may have, and the longer the recovery
time will be. Conversely, lower levels of stress may be associated with fewer symptoms and shorter recovery times.
Although it is beyond the therapist’s scope of practice to counsel clients, you may take note of their emotions and emotional reactions to their conditions. For
example, you have a client who starts crying when
describing the effect of back pain on his or her life and
the feelings of worthlessness it causes. Without diagnosing any specific medical or psychological condition, you
could note that the client is very distressed as a result
of the back pain. This notation may offer you and other
healthcare providers insight into the client’s condition
and response to healing.
Alert
Be extremely careful to stay within your role as a
massage therapist; your scope of practice does not
include diagnosing or counseling.
h
268 INTRODUCTION TO MASSAGE THERAPY
It is much better to offer genuine caring and concern
about the client’s condition than to offer inappropriate
advice.
Good documentation depends on good communication
as you engage clients in effective interviews. Establishing
rapport through communication, making certain assumptions about the client, using reflective listening skills, asking
open-ended and leading questions, and paying attention to
nonverbal messages all help you gather accurate, complete
information for documentation.
Documentation
Within the healthcare community, documentation is used
to create and maintain a patient’s record and to develop initial treatment plans as well as session-to-session treatment
plans. Documentation is a guideline for safe and effective
treatment and proof of the client’s progress, and it is the
basis for communication between healthcare professionals regarding a client’s health. As massage continues to
develop as a healthcare profession and governmental licensure becomes prevalent, the need to learn documentation
becomes more critical because licensed healthcare practitioners are legally required to document patient progress.
Many insurance companies require professional documentation for reimbursement. There are therapists who do not
keep accurate records of client progress because they consider it unnecessary at the time, think it takes too much
time, or do not want to bother clients with paperwork and
interviews. Realistically, most clients are not interested in
filling out forms or sitting through an interview. Most of
them just want to get on the massage table, receive treatment, and go home.
• You convey and breed trust by conducting a professional interview that ensures that your treatment
will be purely professional.
• You convey the importance of health history and
progress by writing it down instead of trying to
remember it.
• You can show clients that their goals were reached
with money well spent.
• You have written records to share with insurance
companies, both to get reimbursed and for accident
and injury settlements.
• You have written records to share with the clients’
other healthcare practitioners to ensure that treatments are cooperative rather than contradictory.
• You have written records to share with healthcare
practitioners who refer clients to you, thus closing
the communication loop and marketing and presenting yourself as a professional.
• You have written records to protect you in the rare
case of a malpractice suit.
As you can see, keeping written records in an organized
file system is a worthwhile investment for the safety of your
clients, the education of your clients, the financial success
of your practice, and the professional image of your practice. Client files must represent accurate information that is
pertinent to treatment. The file should include client contact information, the client’s signed informed consent for
care (discussed in the Ethics and Professionalism chapter),
and basic treatment information, whether in a SOAP note or
in another format. It should include any referrals made and
any self-care recommended.
Alert
Reasons for Documentation
Despite the impatience of clients who “just want to get a
massage,” maintaining a client-centered and successful
practice requires documentation of both wellness and therapeutic massage for many reasons:
• You must understand the clients’ health history
to ensure that there are no contraindications for
massage.
• You can treat repeat clients more efficiently when
you know which techniques were effective.
• You can encourage clients’ participation by inquiring
about their self-care activities.
• You have written proof to illustrate progress toward
the clients’ goals.
• You promote professional massage therapy as a legitimate, aboveboard healthcare practice.
observations regarding behavioral inconsistencies.
you use, techniques clients like or do not like, techniques
that work especially well for a particular client, and the condition of soft tissues from session to session. Documentation
is not only a tool for you; it is also an important method of
communication with other massage therapists or healthcare
practitioners. You may work in a situation, perhaps a spa or
massage clinic, where other therapists may see the same clients. Good documentation will help the treating therapist
gain an understanding of the client’s history and progress
and learn what techniques work well with a particular client.
Additionally, the uniqueness of individuals makes it impossible for any one treatment to work for every person, so clients
The file should not include your subjective or judg-
mental statements, suspected diagnoses, or written
The files can be used to keep track of the techniques
Chapter 6 / Communication and Documentation 269
may choose to use one or several healthcare practitioners
as a collective team. The team approach can be especially
beneficial, as long as the participants share pertinent and
valid information. You need to keep records that a primary
care physician or other healthcare practitioner can understand and, with the client’s signed release of records form,
share any records with referring practitioners as a professional courtesy.
The Health Insurance
Portability and Accountability
Act of 1996 (HIPAA)
In 1996, the Health Insurance Portability and Accountability
Act, better known as HIPAA , was enacted to help employ-
ees and their families obtain and transfer health insurance
coverage when their employment changes or is terminated.
The law was later modified to include Standards for Privacy
of Individually Identifiable Health Information , more
commonly called the Privacy Rule . The modified law not
only gives people better access to health insurance coverage,
it also gives them ownership of their health information and
legally protects that information from being shared without
their written permission. Unfortunately, there is a lot of
confusion regarding HIPAA and the Privacy Rule.
The Department of Health and Human Services
(HHS) has a web site devoted to HIPAA, http://www.
hhs.gov/ocr/privacy/hipaa/understanding/index.html,
that attempts to simplify and explain the law. Included is
a series of questions designed to help people determine
whether or not they must follow the law, but the terminology throughout the questions is confusing and wordy,
and even though the web site defines some of the terms,
the definitions can be unclear. Essentially, you are asked
whether your business provides any kind of healthcare. If
so, you are asked whether anything your business does is
considered a “Covered Transaction” as defined in the law.
Covered Transactions include using any electronic means
to transmit a person’s health insurance information such as
claims, enrollment, eligibility, explanation of benefits, premium payments, claim status, referral certification or authorization, and coordination of plan benefits. If your business
performs any Covered Transactions electronically (computer, electronic media storage, email, internet, personal data
assistants, etc.), then your business is considered a Covered
Entity, meaning that it must comply with HIPAA and follow
all of the rules. If not, which is often the answer for massage therapists, the questionnaire suggests that your business is not a Covered Entity and is not required to follow
HIPAA law. However, there is a “chain of trust” that requires
any business associate of a Covered Entity to be HIPAA
compliant. Business associates include persons, companies,
or entities hired by the practitioner to perform duties that
access, use, or disclose a client’s protected health information (PHI). In other words, if your practice is not a Covered
Entity but you accept referrals from a doctor or clinic, or
you share a client’s progress with his physician, you must
comply with HIPAA regulations. The Covered Entity should
ask you to sign a Business Associate form as part of HIPAA
compliance.
Besides the chain of trust, the regulations of the HIPAA
Privacy Rule require all healthcare practitioners to keep
their clients’ health information private and protected. This
means that all massage therapists must protect their client
records according to HIPAA regulations. Marilyn Allen, a
well-known expert in acupuncture and medical malpractice,
states that it is mandatory that every client’s PHI be kept
private, and that you are considered a Covered Entity if you
gather information directly from clients, through written or
oral communications, or transmit records electronically or
by any other means (including paper and fax).
HIPAA Compliance
To establish and maintain HIPAA compliance, you will need
a way to keep client information protected and private, and
there are specific forms and medical codes you will need to
use. All Covered Entities will use the same medical codes,
as found in the Current Procedural Terminology codebook, the
International Classification of Diseases , Ninth Revision diagno-
sis codebook, and the federal medical devices codebook. In
addition to textbooks for self-teaching, there are a number of
courses that train people for HIPAA compliance. Following is a
list of some of the steps you will need to take to be compliant:
• Designate someone from within or outside the business as the Privacy Officer (the person responsible
for your policies and procedures for handling PHI).
• Establish policies and procedures for keeping PHI
private, and ensure that all employees understand
and follow these rules.
• Develop a manual for HIPAA policies and procedures, including how you will keep or destroy client
records and email communications.
• Use computer firewalls and security software to prevent PHI from being stolen or destroyed.
• Implement the use of passwords and user identifications for anyone who has access to electronic forms
of PHI.
• Obtain written authorization from the client before
emailing any PHI, and make sure the information is
encrypted.
• Include a confidentiality notice on all email, fax, and
paper transmissions of PHI.
• Provide each client with a Notification of Privacy
Policies (NOPP) form as well as a form with their signature indicating that they have received the NOPP.
270 INTRODUCTION TO MASSAGE THERAPY
Anything that has health information related to a particular client must be protected from unauthorized access.
For example, it is unacceptable to set a client’s file on your
desk or anywhere someone could pick it up and look at it.
Likewise, it is not compliant to have client information on
a computer that is accessible to passersby or other unauthorized personnel. Another example of noncompliance is a
sign-in sheet that lists more than just the client’s name, such
as their health insurance company or the primary reason for
their massage appointment.
There are several forms you will need for HIPAA
compliance. The first is called the Notification of Privacy
Policies. It informs clients of the policies and procedures
you follow to keep their PHI private. You can also include
the clients’ rights on the NOPP:
• Clients are entitled to see and receive copies of their
records.
• Clients are entitled to suggest or request amendments to the health information in their files, but the
therapist has the right to not include those amendments in the file, and clients have the right to disagree with the therapist’s refusal.
• Clients are entitled to have a copy of the therapist’s
Notice of Privacy Policies.
• Clients are entitled to object to the privacy policies,
and the therapist then has the right to refuse treatment to those clients.
Once clients have seen your NOPP, they must sign a
separate form indicating their understanding of those policies. Any activity that exposes a client’s PHI or changes
information in their file requires consent and authorization
forms and signatures, and the paper trail of these forms
must be protected and kept private.
Client confidentiality is essential for you as a massage
therapist. It is the ethical way to practice, and the government has only just begun regulating the privacy of health
information. The fine for noncompliance ranges from $100
to $50,000, so check the HHS web site (www.hhs.gov) or
search online for “HIPAA compliance” to familiarize yourself with and follow the law.
Documentation Forms
There are different forms and formats you can use to
document client assessment and massage treatment. You
can choose or create the appropriate forms based on the
information you will document. Essentially, you need to
include contact information for your clients, health history information, informed consent for care, subjective
ideas from your clients about how they feel and what they
want to accomplish, your objective evaluations of clients’
bodies and the condition of their soft tissues, massage
activity and analysis of treatments, and future massage
treatment plans.
The contact information, health history, and informed
consent for care can be consolidated onto one form.
Sometimes called intake forms, these are filled out by clients
at their first appointment, and the forms are kept in your client files. (Figure 6-6 shows an example of an intake form.)
The massage treatment record contains the rest
of the information you need to document: input from
the client, your objective assessments, the massage techniques you use, results of the treatment session, and plans
for future massage treatment. All of the information can
be recorded on a printed form or just written down on a
blank document, as long as the appropriate information is
included.
A common format for documenting massage sessions is
SOAP , an acronym for Subjective, Objective, Activity and
analysis, and Plan information. Figure 6-2 is an example of
a printed SOAP chart, also called a SOAP note, and indicates
the pertinent information to document in each section.
Subjective Information
Generally, subjective information includes any written or verbal information the client shares with you. In addition to the
health history information that clients share on the intake form,
they may tell you what hurts, what they want to accomplish
from the session, the physiological or psychosocial factors that
are affecting their health, and activities they think are affected
by muscular tension or pain. Use effective communication
skills to obtain as much pertinent information as you can from
the client to determine any potential contraindications and to
create the best treatment plan. This chapter focuses on communication skills and the “S” portion of the SOAP note.
Client History
To know where to begin treatment, you need to know
where clients have been—know their history. The history
is the first step in evaluating the client’s condition, and this