Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?
a. Brief SOAP note
b. Comprehensive health history
c. Progress note
d. Referral note
A
Follow-up visits for problems identified in the POMR are recorded in the progress notes. Those visits not identified as problems are recorded using the SOAP format. Careful review of all SOAP notes on a regular basis will detect the emergence of a condition that explains the patient's complaints; at that point, SOAP documentation is stopped.
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