Chapter 6:

Client Plan


“if applicable, conduct an accurate needs assessment, develop a plan of care with the client, and update the plan as needed.”

--NCBTMB Standards of Practice I (j)


In terms of the client, a “needs assessment” and “plan of care” is an assessment of the condition of the client and plan for treatment. Outside of massage strictly for the purpose of relaxation, the client wants to see development as treatment progresses. Accessing their needs and developing a plan of care can be essential in obtaining that outcome. Prewritten questions are better than merely asking the client what the problem is as people don’t always remember everything that’s been bothering them unless specifically asked. Keeping accurate records help assess what therapy works best for the client. These records of proven therapies will also be applicable to future clients with similar conditions.


Over time most therapists eventually stray somewhat from the school formula and develop new techniques: techniques that suit their strength, body type and temperament. Even the therapist who has developed new skills will need to keep records.


Record keeping is particularly applicable when working for another professional. The other person will want to see what progress was made and make sure their instructions were followed. Certain professions may be more inclined to use these records in a legal capacity which stresses the need for accuracy. Less than accurate records might lead a client to receiving a smaller award or judgment than otherwise.


Your role may be part of a larger plan of care embodying other disciplines and other providers. Not doing your part correctly may create a hole that disrupts the entire process.


The NCBTMB requires the therapist keep client records. The licensing agency will likely have requirements along that line as well. At some point it client records may protect you in a civil suit or from a civil suit.


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