Documentation and scope of practice
the process of collecting, confirming, and recording client information
Documentation
primary method used to collect client information
Client Intake
permission given by a client after he or she has been informed of all the relevant facts regarding treatment
Informed Consent
information is obtained from the client or the client's family and friends
Subjective
an order from an authorized health care provider for medications, medical treatments or medical devices
Prescription
Health Insurance Portability and Accountability Act and outlines privacy standards for health care providers
HIPAA
the act of exchanging information through words and behaviors such as body language
Communication
Both the client and the therapist have the right to withdraw or modify consent
information is measurable and verifiable
Objective
act of recommending products or services to address a client's specific problem(s)
Referral
the activities and procedures that can be performed legally by members of a licensed profession.
Scope of practice
client's tone, volume, apprehension, frustration, disappointment, and body language help you understand what is going on behind his or her words.
Nonverbal Communication
when massage would pose a serious health risk to you or your client or make the client's existing condition worse
Absolute Contradictions
Plan, assessment, objective, and subjective
SOAP
client's signed and dated authorization to release his or her medical and personal information to a third party
Medical Release
time frame in which a client could sue you for injury or harm.
Statue of limitations
questions that offer little restriction when answering and allow your client to reflect and clarify thoughts and feelings
Open-ended questions
the process of applying knowledge and expertise to clinical situations to develop solutions that best support the client's therapeutic goals
Clinical Reasoning
Implementation, evaluation, assessment, plan
APIE
If there is nothing to report in a PPALM assessment domain, place a ____ symbol or “∅” rather than leaving it blank.
Null
Recommending, prescribing, dispensing, administering, or changing prescription and over-the-counter drugs, as well as herbal preparations
Out of our scope of practice
the emotional bond people experience when concern is mutually expressed.
Rapport
an acronym for the first letter of the five assessment domains
PPALM
• P urpose of Session
• P ain
• A llergies and Skin Conditions
• L ifestyle and Vocation
• M edical and Surgical Information
condition of client,action taken, response of client,evaluation
CARE
Protect client information by applying the ___ ___ ___
Double Lock Rule