Therapeutic Communications & Client Documentation

These vocabulary flashcards cover core terminology related to client documentation, interview stages, charting formats, communication etiquette, and professional boundaries within therapeutic and wellness practices.

HIPAA (Health Insurance Portability and Accountability Act)

U.S. law that sets strict standards for protecting client health information and confidentiality.

Client File

A confidential collection of all records and forms pertaining to a client’s care and interactions.

Charting

The process of recording session-related information in a client’s file.

Addendum

A dated, initialed note added to a chart to correct or clarify information without deleting the original entry.

Intake Form

A document completed by a new client that gathers personal data, health history, and reasons for seeking services.

Health History

Section of an intake form detailing past and current medical conditions, medications, and surgeries.

Informed Consent

Written permission from a client acknowledging understanding of procedures, risks, and benefits.

Client Policy Form

Document outlining fees, cancellation rules, privacy policies, and practitioner boundaries.

SOAP Notes

Standard charting format with four sections: Subjective, Objective, Assessment, and Plan.

Subjective (SOAP)

Client-reported symptoms and perceptions (e.g., pain location, intensity, duration).

Objective (SOAP)

Practitioner’s measurable observations and immediate treatment results.

Assessment (SOAP)

Practitioner’s evaluation of treatment effect and functional changes in the client’s condition.

Plan (SOAP)

Recommended future actions, goals, and client preferences for care.

Wellness Notes

Simplified charting for relaxation-focused sessions, usually containing Treatment details and Comments.

CARE Format

Alternative charting style: Condition, Action, Response, Evaluation.

Confidentiality

Ethical and legal obligation to keep client information private and secure.

Intake Interview

Initial, often 20-60-minute conversation to build rapport, gather history, and set expectations.

Open-ended Question

Inquiry that invites detailed responses (e.g., “How are you feeling today?”).

Closed-ended Question

Question that limits answers to brief facts or “yes/no” responses.

Initiation Stage

First phase of an interview involving greetings, rapport building, and overview of policies.

Exploration Stage

Interview phase focused on reviewing history, assessing condition, and defining session goals.

Planning Stage

Collaborative development of short- and long-term treatment strategies with the client.

Closure Stage

Final phase summarizing the session, assigning homework, and scheduling follow-up.

Treatment Plan

Blueprint outlining modalities, frequency, goals, and homework for a client’s ongoing care.

Long-range Treatment Plan

Multi-session roadmap linking short-term objectives to broader wellness goals.

Client Compliance

Extent to which a client follows recommended treatments, homework, or lifestyle changes.

Client Education

Providing information or demonstrations that empower clients to manage their own wellness.

Phone Etiquette

Professional standards for answering, speaking, and managing calls with clients.

Appointment Service

Third-party or online system that answers calls and books client sessions on a practitioner’s behalf.

Online Scheduling

Self-serve digital platform allowing clients to book appointments at their convenience.

Email Etiquette

Guidelines for clear, positive, and appropriate electronic correspondence with clients.

Screening (Preliminary) Interview

Brief call or conversation to determine a prospective client’s needs and suitability.

Inappropriate Call

Phone inquiry requesting services outside one’s scope, often of a sexual nature.

Transference

Client’s unconscious redirection of feelings toward the practitioner based on past relationships.

Countertransference

Practitioner’s emotional reactions toward a client that may affect objectivity.

Declining a Client

Politely refusing to begin services with a prospective client due to scope, availability, or other concerns.

Dismissing a Client

Ending an established therapeutic relationship when goals are met or issues arise.

Add-on Wellness Chart

Brief record noting treatment specifics and client preferences in spa-type settings.

Confidential Electronic Charting

Using secure, HIPAA-compliant software to document client sessions digitally.

Charting Tip: No Alterations

Do not erase or delete entries; instead, correct mistakes with a single line, initials, and date.