Spa Vargas University
MT101 Introduction to Massage Therapy
Spa Vargas University
MT101 Introduction to Massage Therapy
Chapter 5: Communication and Documentation
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Introduction
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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
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Effective Communication and Interviewing
Skills
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Rapport attributes
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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
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Establishing Rapport
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Formal introduction
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Verbal communication
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Confident, caring handshake
Maintain eye contact
Using client’s name
Announce technique changes
Offer client a safety mechanism
Disclosure
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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
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Confidentiality
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Clients’ information should be kept private
Sharing clients’ records
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Client must supply written authorization
Examples:
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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)
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
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Certain Assumptions
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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 selfcare
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
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Reflective Listening and Questions
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Reflective listening
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Open-ended questions
 Require a descriptive answer
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Repeat or reiterate the client’s words to convey comprehension
Ask clarifying questions to determine whether you understood
the client
Elicit as much information as possible
Broaden interview beyond yes-or-no answers
Leading questions
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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
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Non-verbal Communication
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Tone of voice
Breathing patterns
Body language
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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
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Documentation
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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
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Reason for Documentation
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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
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Documentation Forms
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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
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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
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S.O.A.P.
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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
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Subjective Information
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Written and oral information from client
Client history
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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
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Chance to sort through the information
Leading questions are useful in clarifying client’s input
Areas covered by interview:
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General
Circulatory
Musculoskeletal
Neurological
Psychosocial
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
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Functional Stress Assessment
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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
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Objective Information
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Massage therapist’s assessment of client
Visual observations
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Palpation observations
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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
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
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Activity and Analysis
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Data covers the massage activity and analysis of the session
Activity includes:
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Techniques client liked or disliked
Effective versus ineffective techniques
Changes made to the massage or flow of the massage
Analysis includes:
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Post-treatment assessment
Prioritized list of functional limitations
Set of treatment goals
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Clarifies progress
Recognizes when goals are met
Goals should be reasonable
Spa Vargas University
MT101 Introduction to Massage Therapy
Chapter 5: Communication and Documentation
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Plan Information
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Future treatment plans
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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
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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
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S.O.A.P. Guidelines
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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
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Summary
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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