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An OT is working with a patient in the in-patient rehab department. The patient recently had a TBI after a motor vehicle accident and has become very agitated. When the OT presents the patient with a grooming activity of brushing his teeth he throws the tooth brush on the floor and states that he wants to be left alone. How should the OT best document the session in the “A” part of the SOAP note? Marked as spam
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