T

Therapeutic Communications & Client Documentation

Client File & Charting Basics

  • Purpose: provide legal record, continuity of care, and proof of service; subpoena-able, must respect HIPAA.
  • Environment differences
    • Medical offices: full charting expected, often electronic.
    • Spas: tight time frames, charting sometimes abbreviated; intake form handled by front desk, info passed on “need-to-know.”
  • Keep documents simple; avoid asking for unnecessary personal data that could breach confidentiality.

Basic Charting Tips (Figure 6.7)

  • Review client file immediately before each session to refresh memory & focus.
  • Write concise, complete notes immediately after each session.
    • Include unexpected events, techniques to focus on next time, client education given, and other pertinent info.
  • Document client statements verbatim using quotation marks; avoid diagnostic labels.
    • Use “Client states he has been feeling…” instead of “Client is depressed.”
  • Maintain confidentiality: only material directly related to sessions.
  • Stick to facts; avoid analysis/judgment.
  • Use only employer-approved abbreviations/symbols.
  • For electronic records: ensure HIPAA compliance; upgrade tech skills as needed.
  • Never erase information; if an error occurs
    • Draw single line through error, add initials & date, or attach an addendum.

Client Forms Overview

  • Every client should complete:
    • Intake form (may combine with health info)
    • Health information/history form
    • Client policy & fee form
    • Informed consent form
  • Optional / situational forms
    • Pain or injury questionnaires
    • Treatment plan template
    • Financial/insurance agreement
    • Medical records release
    • Session charting sheets
  • Secure written permission before sharing any information with another provider.

Intake Forms: Fundamental Facts & Disclaimers

  • Core data to gather
    • Name, address, phone(s), email
    • Medical history & chief complaints
    • Current medications
    • Reason(s) for seeking services
  • Common disclaimers
    • “Massage is non-sexual.”
    • “Services are not a substitute for medical diagnosis; consult a physician for ailments.”
  • As needs evolve, update or add forms (e.g., fee acknowledgements, pain scales, insurance details).

Session Forms

  • Two main charting frameworks
    1. SOAP notes (Subjective, Objective, Assessment, Plan)
    2. Wellness notes (simpler, relaxation-focused)
  • SOAP details (Figure 6.8)
    • SUBJECTIVE: client-reported symptoms, location, intensity, duration, frequency, onset; use quotes.
    • OBJECTIVE: practitioner observations & immediate treatment results.
    • ASSESSMENT: changes due to treatment, positive/negative, functional goals.
    • PLAN: recommended actions & client preferences.
  • Variations: CARE format (Condition, Action, Response, Evaluation).
  • Electronic SOAP systems: ensure HIPAA security; good for illegible handwriting.
  • Wellness chart (spa settings)
    • TX (Treatment): techniques, area, duration.
    • C (Comments): preferences, deviations, progress.
  • Always sign & date every entry regardless of format.

Client Interviews

  • Key purposes: gather info, build rapport, educate, set boundaries & expectations.
  • Initial intake interview length: 20{\text{–}}60\text{ min}; subsequent check-ins shorter but include same 4 stages.

Interview Checklist (Figure 6.9)

• Review file → Greet → Tour → Forms → Policies → Goals → Preview procedure → Assessment → Treatment → Plan → Summarize → Homework → Referrals → Products → Schedule next session.

Timing & Business Impact

  • It costs 6 times more money and 3 times more effort to gain a new client than keep an existing one → investing extra interview time saves resources.

Keeping the Interview on Track (Figure 6.10)

  • Explain agenda & time allotment (“20 min discussion, 45 min treatment”).
  • Redirect rambling kindly.
  • Spa quick-screen questions (recent health challenges, medical care, how body feels today, focus areas).

Artful Phrasing & Question Types

  • Open-ended questions (how, what, when, could) promote dialogue & shared decision-making.
  • Closed-ended questions elicit yes/no or brief answers.
  • Examples (Figure 6.11)
    • Open: “What would you like me to focus on in this session?”
    • Closed: “Shall we focus on your headaches today?”
  • Use quantitative follow-ups: “Rate the pressure 1{-}10,” “How long have symptoms lasted?”
  • Offer option-rich comfort questions: “Blanket on feet/legs or fully covered?”

Standard Interview Questions (Figure 6.12)

  • Physical/emotional condition, onset, intensity, aggravating/relieving factors.
  • Stressors, long-term goals, session objectives, mobility assistance needs.
  • Experience with modality & results.
  • Current medical care, meds, supplements.
  • Product use, expectations, concerns, preferences for effective/enjoyable session.

Interview Stages

  1. Initiation
    • Introduce self, review policies, discuss expectations, build rapport.
  2. Exploration
    • Review history, clarify responses, perform assessments, determine session goals, obtain informed consent.
  3. Planning
    • Co-create long-range treatment plan (frequency, modalities, homework, referrals, indications/contraindications).
    • Set realistic short- & long-term goals; provide evidence-based guidelines (e.g., “twice per week for 2{-}3\text{ wks}, then weekly for 3\text{ mo}, taper to twice monthly”).
  4. Closure (Exit Interview)
    • Summarize treatment, link feelings to work done, adjust plan, assign homework, schedule next visit.

Top 10 Essential Interview Elements (Figure 6.13)

1 Listen actively 2 Reflect 3 Clarify 4 Take notes 5 Assess 6 Describe treatments 7 Answer questions 8 Obtain consent 9 Engage client in planning 10 Plan treatments.

Client Compliance Strategies

  • Barriers: discipline, time, money/insurance, social pressures, beliefs.
  • Improve adherence:
    • Explain benefits & rationale.
    • Clarify instructions; have client repeat/demonstrate.
    • Provide printed handouts.
    • Maintain non-judgmental tone if non-compliance occurs; continue recommending.

Client Education

  • Dual role: support body’s healing learning & broaden knowledge.
  • Methods: verbal explanation, demo, video, handouts, homework.
  • Multimodal delivery (auditory + visual + kinesthetic) improves retention.
  • Ask client to demonstrate technique; provide feedback.

Hone Interview Skills

  • Role-play with colleagues (practitioner, client, observer) ≥ 3 rounds.
  • Observer gives feedback on flow, body language, question types.
  • Reflect: Which role hardest? Use insights to improve real interviews.

Client Technology Connection

  • Tech can enhance or hinder practice; ensure proper tools & skills.

Machines vs. Humans

  • Sole practitioners rely on voicemail/text/email; lacks personal touch.
  • Missed calls can cost appointments; consider
    • Appointment service (pays for itself after 1{-}3 sessions).
    • Online self-serve scheduler for 24/7 bookings.

Phone Etiquette (Figure 6.14)

  • Be prepared (pen, schedule, info).
  • Inspire interest: concise 30\text{ sec} description of services.
  • Answer after 2 rings, before 4; smile before speaking.
  • Identify self & offer help (“Good morning, Northwest Health Center, this is Nancy. How may we assist you?”).
  • Speak clearly; personalize with caller’s name.
  • Minimize distractors: no eating, gum, background noise; create sound-proof area if at home.
  • Avoid holds; if necessary
    • Get caller’s name, state expected wait, check back, offer callback.
  • Take notes; return calls within 24 hrs.
  • Focus on service before quoting prices (“What are you needing?”).

Email & Text Etiquette

  • Use email for announcements, info, newsletters.
  • Choose phone when conflict, emotion, negotiation, or complex discussion.
  • Email guidelines
    • Simple, active, positive language (“Remember to…”, not “Don’t forget to…”).
  • Only text for quick/simple Q&A; obtain permission on intake form.

Screening Clients via Phone

  • Conduct preliminary interview to confirm fit & expectations.
    • Name, referral source, motivation (stress, pain), previous success, expectations.
    • Payment source (self, business, insurance).
    • Others attending.
  • If someone else answers phones, provide scripts covering
    • Pricing, scope, cancellations, special needs, insurance, speaking to practitioner.
  • Role-play scripts; keep call length reasonable.

Handling Inappropriate Calls

  • Indicators: late-night calls, silence, request for “full-body,” suggestive tone.
  • Remain professional; briefly educate: “That is not a service I provide; therapeutic massage does not include sexual acts.”
  • Maintain composure; possible future legitimate client or word-of-mouth.

Declining & Dismissing Clients (Figure 6.15)

Reasons to Decline New Client

  • Practice full (provide referral list).
  • Inability to help (outside scope; refer to specialist).
  • Countertransference / strong attraction/repulsion jeopardizing care quality.

Reasons to Dismiss Current Client

  • Discomfort or boundary issues (transference/countertransference, dependency).
  • Lack of results despite appropriate care (document via charting).
  • Completion of goals (celebrate, set new goals if desired).

Professional Approach

  • Use neutral, caring language: “I believe another practitioner could better serve your needs.”
  • Offer referrals; consult supervisors/peers when ethical dilemmas arise.

Key Numerical & Statistical References

  • New client acquisition cost: 6 × money & 3 × effort of retention.
  • Intake interview duration: 20{-}60\text{ min} (initial), 3{-}30\text{ min} (subsequent, depending on setting).
  • Example treatment frequency guideline: twice/week for 2{-}3\text{ weeks} → weekly for 3\text{ months} → twice/month maintenance.

Ethical & Practical Implications

  • HIPAA compliance vital: secure storage, authorized sharing only, electronic safeguards.
  • Accurate, impartial charting protects practitioner legally and supports inter-professional communication.
  • Clear communication & respectful decline/dismissal maintain professional reputation.
  • Technology & scripts enhance accessibility but must preserve human rapport and boundary clarity.