Preliminary Assessment



Articles

Predicting the Length of a Client’s Treatment

Taken from the Massage Therapy Body of Knowledge (MTBOK) Version 1.0

Section 210.5 Assessment, Treatment Planning and Documentation

Knowledge, skills and abilities relating to practices, procedures and relative terminology of assessment, treatment planning and documentation.

Knowledge: Understand basic aspects of assessment process, treatment planning, documentation, procedures and relative terminology.

Understand the science, application, philosophy and legal and ethical factors involved in client/patient assessment


 * • Communication (verbal and nonverbal).


 * • Client/patient consultation, health history and intake procedures/documents.


 * • Subjective client/patient information.


 * • Objective findings gained through observation and palpation.


 * • Postural and functional evaluation.


 * • Plan of treatment based on client/patient assessment, client/patient goals (long and short term).

Physical assessment


 * • Visual and palpatory assessment of tissue, skin, posture and movement.

Basic client/patient documentation components


 * • Informed consent.


 * • Waiver of liability.


 * • Medical release.


 * • Medical clearance.


 * • Health history and current condition/status.


 * • Record of:


 * - Client/patient name.


 * - Session date.


 * - Client/patient health concerns/considerations for treatment.


 * - Assessments and findings, if applicable.


 * - Treatment administered.


 * - Treatment outcomes and goals.

Treatment plan


 * • Purpose of the session(s).


 * • Collection and interpretation of client information and assessment findings.

Health Insurance Portability and Accountability Act (HIPAA) regulations that apply to massage therapy


 * • Client /patient confidentiality.


 * • Storage, maintenance/security, transport and release of client/patient personal health information (PHI).

Skills


 * • Demonstrate the ability to conduct a client/patient interview including a health history and client/patient consultation.


 * • Perform assessment procedures including visual, auditory, verbal, written and physical evaluation/palpation.


 * • Perform posture and movement analysis as they relate to the treatment plan.


 * • Use palpation to locate, assess and treat tissues during pre-massage assessments and those used during the session.


 * • Demonstrate effective communication skills including writing, listening and speaking.

Abilities


 * • Obtain legal written informed consent initiating the professional relationship and prior to administering massage therapy.


 * • Read and interpret client/patient intake and health history form.


 * • Determine appropriate treatments based on client/patient health history, intake form and client/patient consultations (initial and follow-up).


 * • Formulate a treatment plan based on findings from a health history, an intake interview and an assessment process.


 * • Explain the treatment plan, intended outcomes and potential adverse outcomes to the client/patient and gain consent, including framework for how to modify the plan based upon feedback, prior to administering massage therapy.


 * • Generate relevant charting documentation for each session which meets legal requirements for health care and wellness practitioners.


 * • Prepare, maintain and safeguard client/patient records in accordance with federal, state and municipal laws.


 * • Explain chosen techniques and relate the choice back to the physiological, psychological and anatomic effectiveness of the technique.


 * • Describe how to refer client/patient to appropriate healthcare provider when client’s/patient’s needs exceed the skills and abilities of the therapist or are outside the massage therapy scope of practice.


 * • Modify a treatment plan during subsequent sessions based on changes in the client’s/patient’s health or desired outcomes [1, 13, 45, 67, 85, 112].