Foundation of Ethics 

The therapeutic process, as defined in this course, consists of assessment, action, documentation, and outcome.  It is important that we as therapists handle each step honestly, ethically and professionally to be beneficial to our clients.

 

Assessment is the gathering and interpreting of information that we obtain from the client, other health professionals, and our observations.  Assessment requires that you pay attention to what a client needs so that you can provide the appropriate service and the most effective therapeutic action.  Just to clarify, assessment is not a diagnosis. Massage Therapist are not allowed to diagnose illness in any condition under any circumstance.  Diagnosis is the naming of a condition or problem. Only physicians and nurse practitioners are allowed to give medical names to illnesses.  It is important that we assess our clients only by what we see or in most cases feel.

Documentation of Information

 

It is important for you to document what you find from each client's session. Record your assessments by using Subjective information (symptoms and client experiences) For example, pain, anxiety, stress, etc. Objective information (signs measured by the therapist) For example, muscle tightness or range of motion.

These assessment notes are important for several reasons:

 

• it can be difficult to remember the details about each client between visits

• it allows you to track the clients progress over time

• often written records are required for insurance claims, lawsuits, etc

• Many states require by law that a therapist keep these records for a determined period of time

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Focus on the Client’s Goals.  At the start of each client’s session, it is very important to ask the client, “What is your primary goal from this session?” The client’s answer will guide your focus. “I don’t know,” is not an acceptable answer, and requires further questioning.  As the therapist, you can coach your client by giving examples of how other might respond to the question.  Let them know that some people’s goal is to relax, while some want to reduce pain and stiffness, etc. By explaining others responses, it should encourage your client to speak up about their needs.

 

If a client is asking for services that you are not comfortable performing, whether it is a modality that you have not been trained in or something that is inappropriate, it is important that you communicate this quickly and tactfully. Always stay within your scope of practice, the indications and contraindications for your work, your education and your experience and your boundaries. For instance, a client might ask you to adjust his/her back during his/her massage.   This is outside the scope of practice for a massage therapist unless you are also a chiropractor. After addressing an issue such as this, and you and the client are unable to reach a mutual understanding of the session’s goal, then it is better for both of you to know that and handle it early to avoid problems.

 

Health History/Intake Forms

 

Each massage practitioner should begin each session by having their client fill out a health history or intake form. A health history is a written record of past and current health events, including illnesses, accidents and surgeries that the client has experienced in the past or is currently experiencing. Performing a health history on each client will help you in numerous ways:

 

 

• The health history process shows a client that you are willing to take the time to learn about him/her

• The process can give you information about what has let them seek massage therapy and provide you with the information necessary to be the most effective

• The client writing about their health issues often brings about awareness

• If your practice is ever reviewed in a court of law, having written records documents and thus limits your liability

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Consent Forms

Intake forms, as discussed previously, may also include a statement of consent for the work. At the most primary level, a client is giving his or her implied consent for the work when he/she makes the appointment, shows up and follows whatever instructions the practitioner gives.  However, to protect yourself, it is a good idea to have a brief statement that explains what the client should expect during the session along with any important boundaries.  For example, the following is our consent form:

 

Consent for Therapy and Waiver of Liability

 

‘I understand that a Massage Therapist does not diagnose disease, illness or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that draping will be used at all times.  I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session.  I understand that the massage Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status.  I understand that massage therapy is designed to be an ancillary health aid and is not suitable for primary medical treatment for any condition.  I hereby assumes fully responsibility for receipt of the massage therapy, and releases and discharges Therapist from any and all claims, liabilities, damages, actions, or causes of action arising from the therapy received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist, to the fullest extent allowed by law.  I, in signing this consent for Therapy and Waiver of Liability (“Consent”), understands and agrees that this Consent will apply to and govern the current and all future therapy sessions performed by Therapist.'

 

 

Making Referrals

 

It is essential that you know what is within and outside your scope of practice. Review your local, state and professional association guidelines for this information. When your assessment uncovers conditions for which your knowledge or primary modality of massage therapy is contraindicated, then it is important that you refer the client to other health care professionals that can better suit their needs.  A good rule of thumb is “When in doubt, refer out”.  A referral is a recommendation that the client seek the advice of another health care provider.

 

When working with clients who display significant health problems, whether they are physical, mental or emotional, it is best to be working in collaboration with the client’s physician or mental health professional. If this is not possible, then it’s recommended that you ask the client to bring you an acknowledgment from his or her physician or mental health professional that they are aware the client is working with you.  Whenever possible, it is best to refer the client to the primary care provider (Often referred to as PCP in insurance billing) with whom he/she currently has a relationship. A primary care provider is an MD, DO, DC, ND or NP who provides well visits, evaluates and diagnoses illnesses and coordinates the plan of treatment.

 

If the client has no current relationship with a health care practitioner, then it is appropriate to give him/her a specific practitioner’s name or business card. The best practice is to develop a network of health care practitioners who you know and trust and who will refer clients to you in return.

Conditions to Refer to Primary Care Providers

 

There are an unlimited number of conditions that you might encounter in your practice where it would be appropriate for you to refer out.  The following is a basic list for you to use as a beginning point. You may want to post this in your practice for reference.

 

Refer Clients with These Conditions to Primary Care Providers:

 

• acute pain (sharp and localized; either deep or superficial)

• unexplained fatigue, muscle weakness or weight loss

• acute inflammation of any kind (heat, redness, swelling, pain)

• unexplained lumps and skin changes, including rashes

• unusual swelling (edema) or an increase in existing swelling

• signs of infection or contagious disease (fever, chills, sweating)

• bleeding

• fractures or dislocations

• unexplained or extensive bruising

• stomach pain, nausea, vomiting and/or diarrhea

• unusual coldness or coloration in any part of the body

• any area having decreased sensation

• signs or symptoms of acute phlebitis or deep vein thrombosis (heat, pain, redness and/or swelling, especially in a leg)

• enlarged lymph nodes, with or without pain or tenderness

 

 

Refer clients with these conditions to Primary Care to Mental Health Care Providers:

 

 

• severe, disabling or dysfunctional behaviors

• unexplained mood changes

• hallucinations

• actual or threats of violence to self or others

• severe crying, grief and/or expressions of loneliness

 

 

Use extra caution when working with a Client who is:

 

• taking medication that may affect  tissues, including blood, lymph or bone

• has immune system concerns

• recovering from acute trauma, including accidents, surgeries

• has physical wounds

• pregnant

• has cancer

 

 

Indications and Contraindications

A therapeutic action is usually contraindicated for one of the following reasons:

 

 

• the action might be harmful to the client by direct negative effects or by delaying the client’s arrival at the most effective treatment

• the action might be harmful to the therapist or other persons

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If either of those two reasons are present, the action is considered contraindicated.  If you find yourself in a position where you are unsure if something is contraindicated it’s always a good idea to follow the old edict, “when in doubt, don’t.”

Lists of general contraindication guidelines are available such as the ABMP website, massage therapy magazines and textbooks.  However, there is no clear agreement among them. The continual and on-going study of the therapeutic response of massage therapy about anatomy, physiology and pathology is a requirement for true professionalism.

It is recommended to keep a copy of Pathology by Susan Salvo or Ruth Werner, a reference guide for massage therapists in your office or therapist library.

Evaluating Therapeutic Outcomes

 

A therapeutic outcome is the effect your work has on the client. Evaluation means determining the value of your services. The primary way to evaluate the outcome of your therapeutic actions (or treatments) is to compare the assessment information you obtained before the therapeutic action (the clients first session) with the assessment information you obtain by re-testing at the end of their last session. Important areas to reassess include pain scale, anxiety, range of motion, muscle tension or any other subjective or objective factor that you previously assessed.