NCBTMB Communication and Documentation 5 — Questions and Answers
Question 1: A client mentions they were recently diagnosed with cancer but asks you not to tell anyone. Which action is MOST appropriate?
- Share the information with the client's primary physician immediately
- Honor the confidentiality and document the disclosure in the client's record only (Correct answer)
- Refuse to treat the client until medical clearance is obtained
- Ignore the disclosure since massage is generally safe
Correct answer: Honor the confidentiality and document the disclosure in the client's record only
Confidential disclosures must be documented in the client's record, and treatment decisions (including potential referral) should be made collaboratively with the client.
Question 2: Nonverbal communication cues a therapist should monitor during a session include:
- The client's insurance information
- Client facial expressions, muscle guarding, and breath-holding (Correct answer)
- The therapist's own verbal explanations only
- Room temperature and ambient lighting
Correct answer: Client facial expressions, muscle guarding, and breath-holding
Monitoring nonverbal cues like guarding and breath-holding helps the therapist adjust pressure or technique in real time.
Question 3: Which behavior BEST demonstrates professional boundaries in a therapeutic relationship?
- Sharing personal problems with clients to build rapport
- Maintaining consistent policies for all clients without personal exceptions (Correct answer)
- Accepting gifts of significant monetary value from loyal clients
- Continuing sessions beyond scheduled time when clients are talking
Correct answer: Maintaining consistent policies for all clients without personal exceptions
Consistent, equitable policies for all clients maintain professional objectivity and prevent boundary erosion.
Question 4: The Plan section of a SOAP note should document:
- The client's diagnosis
- Recommendations for future sessions, home care, and referrals (Correct answer)
- The palpation findings from today's session
- The client's insurance copay
Correct answer: Recommendations for future sessions, home care, and referrals
The Plan section outlines next steps including frequency, home care recommendations, and any referrals made.
Question 5: During intake, a client asks whether massage will cure their chronic back pain. The therapist's BEST response is:
- 'Yes, regular massage is very effective at curing back pain.'
- 'Massage cannot cure conditions; I can explain how it may help manage your symptoms.' (Correct answer)
- 'I cannot discuss outcomes; please ask your doctor.'
- 'That depends entirely on how many sessions you purchase.'
Correct answer: 'Massage cannot cure conditions; I can explain how it may help manage your symptoms.'
Therapists must not make curative claims; accurately framing massage as supportive care upholds scope of practice and ethical communication.
Question 6: A client wishes to record the intake consultation on their phone. The therapist should:
- Always refuse to protect privacy
- Use professional judgment, document the client's request, and establish mutual consent (Correct answer)
- Allow it without any discussion
- End the session if the client insists
Correct answer: Use professional judgment, document the client's request, and establish mutual consent
Recording raises privacy and consent concerns for both parties; professional judgment, clear mutual consent, and documentation address these appropriately.
Question 7: Which of the following is NOT appropriate to include in a client's massage therapy record?
- Session duration and techniques used
- The therapist's personal opinion about the client's lifestyle choices (Correct answer)
- Objective tissue findings and client-reported outcomes
- Informed consent and contraindication notes
Correct answer: The therapist's personal opinion about the client's lifestyle choices
Client records must be objective and clinically relevant; personal opinions about a client's lifestyle are inappropriate and unprofessional.
NCBTMB Communication and Documentation 5
A client mentions they were recently diagnosed with cancer but asks you not to tell anyone.
Which action is MOST appropriate?