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Abnormal behavior is typically recorded in the "S" (subjective) section of SOAP notes. This is where the healthcare provider documents the patient's self-reported symptoms, including any observations of abnormal behaviors that the patient exhibits.

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Q: Where in the SOAP notes do you record abnormal behavior?
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What is the form that allows the physician to record findings in the medical record?

Medical records use different formats. One of the most popular formats is the SOAP note. SOAP stands for:S = subjectiveO=objectiveA=assessmentP=PlanNote that the medical record rarely uses a "form" for physician notes, but uses a "format", often including a narrative section.Some institutions require SOAP notes from nurses, but other institutions use varying types of notes.


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The record format you are referring to is likely the SOAP note format used in medical documentation. SOAP notes include subjective information (S), objective data (O), assessments (A), and plans (P), making it a structured format for healthcare professionals to document patient encounters.


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In a POMR or problem oriented medical record, the record is kept together by problem number (a number is assigned to each problem. Progress notes in these records are kept in SOAP format. S=subjective (chief complaint, present illness), O=objective (physical exam, labs), A=assessment (diagnosis, prognosis), P=plan (treatment). In a SOMR or source oriented medical record, the record is kept together by subject matter (labs are all together, progress notes are all together). Progress notes in a SOMR are written in paragraph format.


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The form in the medical record that contains subjective info about the patient's past illness is called a SOAP note. SOAP is the acronym for subjective, objective, assessment, and plan.


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What is the difference between soap notes and cheddar notes?

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