This seems like a silly question but it's been bugging me so here goes anyway. I have two clients who presented with a 'throat phobia' that they've had since childhood. And one who is allergic to everything and requests I use nothing but baby oil on her. One doesn't want her face touched and there are a few others with those kinds of concerns. I've been putting 'throat phobia' or 'baby oil only', etc. circled at the top of their original SOAP note so that when I pull their chart I see it right away as I wouldn't want to overlook that. Would it matter if I have something like that on the page out of format if my records were ever requested for court or something? Or is this something I should put on a separate page?
~Sandra
~Sandra