Communication and Documentation Flashcards
7 cards from real NCBTMB practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Communication and Documentation flashcards as text
A client arrives and seems emotionally distressed but does not volunteer information. The MOST appropriate therapeutic communication technique is:
Answer: Use open-ended questions and reflective listening
Open-ended questions and reflective listening create a safe space for clients to share at their own comfort level.
Which of the following BEST describes the purpose of a treatment plan in massage therapy?
Answer: To outline goals, modalities, and frequency to guide ongoing care
A treatment plan provides a structured roadmap of client goals, proposed modalities, session frequency, and measurable outcomes.
A client reports a new medication since their last visit. The MOST important reason to document this is:
Answer: To identify potential contraindications that may affect treatment
Medications can affect tissue response, blood pressure, sensation, and contraindicate certain techniques, making documentation clinically essential.
When a client asks for a copy of their session records, the therapist should:
Answer: Provide copies within a reasonable timeframe per applicable state law
Clients generally have a legal right to access their own health records; therapists must comply within state-mandated timeframes.
Which of the following is an example of a SMART treatment goal?
Answer: Client will report 50% reduction in neck pain on a 0–10 scale within 6 sessions
SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound; a numeric pain scale with a session deadline meets all criteria.
A third party (e.g., attorney) requests a client's massage records. The therapist must FIRST:
Answer: Obtain a signed written release of information from the client
A written, client-signed release of information is required before disclosing records to any third party, including attorneys.
The Assessment section of a SOAP note typically contains:
Answer: The therapist's clinical interpretation of findings and progress toward goals
Assessment reflects the therapist's clinical reasoning about the client's condition and how it compares to previous sessions.