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Chapter 02: Treatment Planning: Intake, Consent, and Documentation
Salvo: Mosbyโs Pathology for Massage Therapists, 4th Edition
MULTIPLE CHOICE
1. Which part of the massage session is based on the clientโs health history, the interview, and
other assessments?
a. Intake form
b. Treatment plan
c. Informed consent
d. Referral form
ANS: B
A treatment plan is devised based on information gathered from clientโs health history,
interview and other assessments.
REF: p. 18
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
2. What process involves evaluating a clientโs condition based on subjective reporting and
objective findings?
a. Countertransference
b. Progress report
c. Documentation
d. Assessment
ANS: D
Assessments involve evaluating a client based upon subjective reporting and objective
findings.
REF: p. 19
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
3. Which term refers to information such as client experiences and symptoms as learned from
the client during an intake?
a. Informed consent
b. Subjective data
c. Palpation assessment
d. Objective data
ANS: B
Subjective data is based upon client perceptions of their experiences and symptoms.
REF: p. 32
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 6.5 (Documentation and Client Files)
4. Which term refers to data that is measurable and verifiable?
a. Subjective data
b. Informed consent
c. Objective data
d. Scope of practice
ANS: C
Objective data refers to the visual and palpation based information that is measurable and
verifiable during the intake process.
REF: p. 32
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 6.5 (Documentation and Client Files)
5. On an intake form, if a massage therapist records information upon the form, the massage
therapist needs to
a. use a different color pen.
b. write it in pencil so it can be erased.
c. place initials next to the entry.
d. highlight the information.
ANS: C
Placing initials next to client entries ensures accuracy of record keeping by the massage
therapist.
REF: p. 8
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 6.5 (Documentation and Client Files)
6. Which question is considered open-ended?
a. โOn a scale from 1 to 5, what is your level of pain today?โ
b. โDoes your shoulder still hurt?โ
c. โDid you feel any pain in the area that was treated in the last session?โ
d. โWhat can you tell me about your pain level today?โ
ANS: D
An open-ended question allows a client to elaborate upon an answer as opposed to
close-ended questions which require an affirmative answer.
REF: p. 13
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
7. Which should the massage therapist avoid doing when interviewing a client?
a. Using both open-ended and closed-ended questions
b. Staying focused on what is being said
c. Indicating that a response is right, wrong, or interesting
d. Listening intently and signaling interest
ANS: C
A massage therapist needs to remain neutral in their approach to interviewing a client.
REF: p. 13
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
8. Internally rotated shoulders with head forward posture is an example of
a. objective data.
b. subjective data.
c. palpation results.
d. morbidity.
ANS: A
Internal rotation of the shoulders is a visible and verifiable item to witness within a clientโs
posture.
REF: p. 32
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
9. Which term describes the emotional bond people experience when mutual concern is
expressed?
a. Communication
b. Palpation
c. Rapport
d. Inspection
ANS: C
Rapport is the emotional bond a massage therapist creates when expressing genuine concern
for a client.
REF: p. 11
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
10. Clients providing clear answers to a therapist is essential in order to provide
a. an efficient means to scheduling other clients.
b. communication with other health care providers.
c. effective treatment planning for the client.
d. an appropriate fee structure of the sessions.
ANS: C
Effective treatment planning entails receiving accurate clear answers from a client.
REF: p. 18
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
11. If a client who normally receives deep tissue sessions refuses to receive a deep tissue modality
on a particular session date, the therapist should
a. stick to the techniques outlined in the original treatment plan.
b. tailor the session to the clientโs demands on that day.
c. suggest that it be revisited after the primary complaint is resolved.
d. tell the client their usual bodywork is always appropriate.
ANS: B
Right of refusal determines that a client can request modifications of treatment plans at any
time.
REF: p. 17
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
12. Which statement describes nociceptive pain?
a. Pain resulting from nerve damage from an injury
b. Pain resulting from nerve compression syndromes
c. Pain resulting from nerve degeneration
d. Pain resulting from infectious nerve disease
ANS: A
Pain resulting from injuries and resultant tissue damage is referred to as nociceptive pain.
REF: p. 22
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
13. When performing the treatment plan, the massage therapist should
a. follow it to the letter, even if the clientโs goals change.
b. realize 50% improvement in function is insufficient.
c. accomplish complete freedom from pain for the client.
d. realize 100% function and pain relief may be unachievable.
ANS: D
Providing realistic expectations will be a sound method to formulating treatment plans.
REF: p. 31
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
14. Because lubricant sensitivity cannot always be predetermined, the massage therapist should
have
a. talcum powder available.
b. gloves available.
c. the option of using a hypoallergenic lubricant.
d. the ability to massage the fully clothed client.
ANS: C
Hypoallergenic lubricants will aid individuals with sensitivities to lubricants.
REF: p. 15
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 82.0 (Core Concepts of Massage and Bodywork Application)
15. What does the Implementation portion of an APIE note entail?
a. The treatment strategies formulated for future sessions.
b. The methods and techniques employed in the present session.
c. The subjective and objective data derived from the client.
d. The responses witnessed physically and emotionally from sessions.
ANS: B
The methods and techniques implemented during a present session will be recorded under the
Implementation section of an APIE note.
REF: p. 33
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
16. If a massage therapist accepts a prescription order for massage, the order must specify
a. massage therapy only.
b. physical therapy and massage therapy.
c. physical therapy only with release for massage.
d. massage and bodywork only.
ANS: A
If a massage therapist accepts a prescription for therapy, the prescription must specify
massage therapy, not physical therapy or occupational therapy. The prescription may instruct
the massage therapist to evaluate and treat at his or her discretion, or it may state a specific
method, such as soft tissue mobilization or massage therapy. Prescriptions must be followed
exactly, or they may be challenged by an insurance company or court of law.
REF: p. 34
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
17. If a client begins taking anticoagulant drugs after a treatment plan has been established, an
example of an effective modification of the initial treatment plan is to
a. employ a light touch modality to limit the chance of bruising.
b. utilize massage tools to provide more effective deep tissue touch.
c. suggest a hydrotherapy treatment to replace a touch modality.
d. perform strokes to intensify cardiovascular activity.
ANS: A
Since anticoagulant drugs will increase the chances of bruising, a light touch modality will be
the best option.
REF: p. 28
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
18. Which should the massage therapist do when assessing a clientโs pain?
a. Determine the original cause because it is essential.
b. Ask the client questions using the acronym OPPQRST.
c. Accept only the terms mild, moderate, or severe to describe the quality of pain.
d. Ask the client questions using the acronym CARE.
ANS: B
The acronym OPPQRST will ask pertinent questions related to a clientโs pain.
REF: p. 20
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 43.5 (Client Assessment)
19. The term for the capacity of individuals to obtain and understand information and services to
make appropriate health care decisions is
a. active communication.
b. assessment literacy.
c. health literacy.
d. diagnostic assessment.
ANS: C
Health literacy is defined as the capacity of individuals to obtain and understand information
and services to make appropriate health care decisions.
REF: p. 8
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 13.0 (Using Anatomic and Health Care Terminology)
20. Which type of form is filled out by a health care provider to authorize massage therapy
treatment?
a. Intake
b. Informed consent
c. Medical release
d. Referral
ANS: D
A referral is used to authorize massage therapy treatments by another health care provider.
REF: p. 35
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 13.0 (Using Anatomic and Health Care Terminology)
21. Which guideline is part of the Health Insurance Portability and Accountability Act (HIPAA)?
a. Assign passwords to those who access electronic client files.
b. Obtain verbal permission from clients to send them marketing materials.
c. Store client files in an unlocked cabinet.
d. Obtain verbal consent from each client prior to treatment.
ANS: A
HIPPA pertains to all electronic data of health records.
REF: p. 39
TOP: MTBOK: section 210.5 (Assessment, Treatment Planning and Documentation)
MSC: ELAP: section 6.5 (Key Principles of Documentation & Keeping Good Client Files)
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