social work soap note example

Soap Note Example. Get an x-ray of the left hip. Business Case. Whether you are a licensed clinical social worker or an MSW social worker, if you have a case load, chances are you need to write case notes: also referred to as progress notes. Learn More . The plan is the final part of the SOAP note, and it includes the relevant interventions for the patient’s case. Example 2: Suzy. Documentation of all patient contact is one of the main responsibilities of a medical social worker. The assessment should also note possible areas of further inquiry or testing to guide proper treatment of the individual or family members. SOAP notes, are a specific format used for writing a progress note.This packet of 8 professionally created SOAP notes and Progress Notes can be downloaded and customized with your letterhead immediately.These notes were created for mental health care professionals: counselors, social workers, psychologists etc. May 14, 2018 - Explore Stacey T's board "soap notes" on Pinterest. R.A is a 16-year-old female with type 1diabetes first diagnosed 5 years ago. Your email address will not be published. Download 28.50 KB #11. Advertisement. SOAP notes are used by many professionals including social workers, physicians, counselors and psychiatrists. SOAP Note for Counseling Sessions (PDF). Case Documentation In Counseling And Psychotherapy. At the end of this discussion, an example of a SOAP note for a particular clinical problem is presented. This one has more serious consequences. The SOAP notes, as discussed throughout this article, is a kind of medical note used by health care providers to accurately document and record patient’s condition during treatment. Counselling Notes Examples . 2. Example: Client was alert and attentive during therapy. The only words typed by the clinician are highlighted in yellow . While the simple note is a note commonly used by many people to write down information so that they will not forget it. A SOAP note template comes in a very structured format though it is only one of the numerous formats health or medical professionals can use. May 14, 2018 - Explore Stacey T's board "soap notes" on Pinterest. ♦ Example: Needs support in dealing with scheduled appointments and taking responsibility for being on time to group. Soap Notes Physiotherapy Template. Describe final recommendations or treatment to be used by the client in the plan section of the SOAP notes. For example, a patient may have heart disease, diabetes, severe anxiety and a surgical wound. Medications: Albuterol. 2. SOAP notes are used so staff can write down critical information concerning a patient in a clear, organized, and quick way. O: Objective Data Includes – Counselor observations stated in measurable/factual and observable terms without interpretation, P: Progress and /or plan – Counselor documents. She does not report any episodes or symptoms of hypoglycemia. • Good progress note: Assisted Janea with shopping. The soap notes template is an easy and an… 2. A SOAP note template by a nurse practitioner or any other person who works with the patient enters it into the patient’s medical records in order to update them. This sample SO AP note was created using the ICANotes Behavioral Health EHR. She attended the University of Nebraska where she majored in English. Business Case Template. Aug 10, 2017 - To ensure that a patient gets the perfect treatment, hospitals often employ the SOAP analysis by writing down a sample soap note. These are a red flag for insurance claims reviewers. Assessed symptoms. Some other items a Social Worker should document in their case notes: CLICK HERE To have a look at or to purchase a comprehensive set of Case Note Templates in SOAP and general format. It may also include information from other people including doctors, family members or neighbors. Download 26.50 KB #15. Unless when she has an emergency, she usually comes to the hospital for follow-up every month. Business Case Example. SOAP Note Example. While SOAP is a more popular format in medicine, the Data, Assessment, Plan paradigm is potentially more appropriate for behavioral health. Download 90.50 KB #19. Note that the SOAP contains A few steps for the brave that want to venture into a similar template for themselves. The note includes a particular order and components. Case notes are a struggle for most social workers and therapists. The Objective portion of a SOAP note includes factual information. ), and include whatever information an insurance company would need to see to justify your continued involvement with the patient. The following is an example of a SOAP note: Subjective. Explore. … Good notes provide documentation that the therapist is following acceptable standards of care, utilizing appropriate interventions, describing the results of these interventions, and documenting the disposition of the case. Whether you are in the medical, therapy, counseling, or coaching profession, SOAP notes are an excellent way to document interactions with patients or clients.SOAP notes are easy-to-use and designed to communicate the most relevant information about the individual. Sample SOAP Note. This covers both the social worker's personal observations of the client and any objective information from outside sources such as medical reports or the results of psychiatric testing. 21 Gallery of Soap Notes Template Social Work. Soap Notes Assessment Example. Save my name, email, and website in this browser for the next time I comment. Most mental health clinicians utilize a format known as SOAP notes. #3 Figure out the patient’s goals. If you're using EMR software, you should find an option with a wide selection of content that's able to be customized with unique responses, outcomes, and goals tailored to each child. components. Subjective: This is the part of the […] First, you have to understand what a SOAP Note is and why it is used. More information... People also love these ideas. For patients who are followed for ongoing and continuous social work services such as our automatic referrals to Rehab, ICU, and Hem/Oncology, the minimum requirement is a once per week summary inpatient progress note. In a future post, we’ll tackle how to get your visit notes done quickly. Whether you are in the medical, therapy, counseling, or coaching profession, SOAP notes are an excellent way to document interactions with patients or clients.SOAP notes are easy-to-use and designed to communicate the most relevant information about the individual. You might remark that they have been drinking a lot lately, especially after stressful days at work. Social Workers, see a sample SOAP note and learn the most important components of writing SOAP Notes. The client indicated that she has persistent suicidal thoughts about overdosing on her medications. Sample SOAP Note For Social Workers Posted on August 4, 2015 by admin Whether you are a licensed clinical social worker or an MSW social worker, if you have a case load, chances are you need to write case notes: also referred to as progress notes. Progress notes can be in the language the PSW writes in. Sample SOAP Note. Chief Complaint: 23-year-old male presents w/ a chief complaint of: “my lower left back jaw has been sore for the past few days” P:Update blood work to include sed rate and rheumatoid factor. At the end of this discussion, an example of a SOAP note for a particular clinical problem is presented. SOAP Note tool kit and other forms for professional counselors, social workers and psychologists. Generally speaking, a SOAP note is a short form organizing a patient’s personal and medical information and they are used primarily for admissions, medical history, and a few other documents in a patient’s chart. 3. • Better progress note: Assisted Janea with grocery shopping, budgeting, making change, talking with people, and transportation. Download 28.50 KB #16. Whether you are a licensed clinical social worker or an MSW social worker, if you have a case load, chances are you need to write case notes: also referred to as progress notes. For example, the patient is doing well. SOAP notes, once written, are most commonly found in a patient’s chart or electronic medical records. Jul 24, 2018 - Write better pediatric occupational therapy SOAP notes to speed up the documentation process and get paid faster. Required fields are marked *. Write details down as factually as possible. Interested to see what this all looks like in (semi) real life? We will write a custom Case Study on SOAP Note specifically for you for only $16.05 $11/page. Business Case Analysis. A = Assessment of the situation, the session, and the client, regardless of how obvious it might be based on the subjective and/or objective statements. She does not report any episodes or symptoms … She … Unless when she has an emergency, she usually comes to the hospital for follow-up every month. More information SOAP Note Examples 301 certified writers online. Business Case Template Ppt. “Client responded well to non-verbal cues” would be your impression of the therapy session and would work well as a point to elaborate on in the subjective section. Soap Case Notes Template. This portion includes all relevant information provided by the client but should remain as brief and direct as possible. Soap Notes … Soap Notes Template Social Work. Hospice social work visit notes made easy. Avoid "cookie cutter" notes that are generic, vague, and/or look the same for all the children you work with. Progress notes can sometimes be viewed as busy work, not central to the client’s progress, or only necessary to fulfill administrative requirements. Now for the second example of notes without adequate sequential tracking. Progress Notes Progress notes are used to record the progress of treatment and are the substance of a client’s case record. You need to include the 5 Ws: the who, what, when, where and why. Soap Notes Example Therapy. Case note templates available for immediate download. Risk assessment – whether there is any danger to self or others and what the plan for addressing is. Your email address will not be published. … Sep 22, 2016 - Through the use of SOAP notes, a social worker documents initial problems, steps taken to resolve the problem and the final results of these treatment steps. Psychiatric Note Example Soap Notes in Psych Nursing. Social Workers, see a sample SOAP note and learn the most important components of writing SOAP Notes. Soap Notes Template Chiropractic. Advertisement. November 9, 2018 by Role. Download 26.00 KB #10. Get an x-ray of the left hip. Today. Sample SOAP Note For Social Workers | Soap Note Example. ♦ Example: 20 minutes late to group session, slouched in chair, head down, later expressed interest in topic. D (data) combines information found in SOAP’s subjective and objective categories, whereas the A (assessment) and P (plan) sections are the same as in a SOAP note. SOAP Note for Coaching Sessions (PDF). Download Soap Notes Example social Work Templates Fortthomas new from acting resume example professional template with resolution : 1275 x 1650 pixel. Soap Notes Template Pdf . Download 28.50 KB #12. SOAP note (An acronym for subjective, objective, analysis or assessment and plan) can be described as a method used to document a patient’s data, normally used by health care providers. Click here for more information about Progress Note Requirements Example #1 Took Janea to the store. Take ibuprofen 600 mg p.o. t.i.d. First, you have to understand what a SOAP Note is and why it is used. The client presented with depressed mood and flat affect. It is not intended as clinical advice nor does it supersede your own way of practicing clinical social work. Although she is asymptomatic, her blood pressure is 170/99 mmHg. November 9, 2018 by Role. PDF Download: Sample Case Note Template; PDF Download: Sample Brief Assessment Template; Making these templates helps me to save a lot of time! This data is written in a patient’s chart and uses common formats. If you are required to write your case notes in SOAP note format this post will give you an example of some of the most important components to include your  SOAP note formated case note. DAP vs. Beyond reading, you will be asked to explore and compare examples of good and bad case notes in context, edit and write case notes based on vignette scenarios provided via interactive media or videos, and share your work with your peers to critique and reflect the process of writing case notes. For every record, you must offer sufficient details; Writing the plan. work for. Below is a fictional example of a progress note in the SOAP (Subjective, Objective, Assessment, Plan) format. However, learning how to write good social work case notes will protect both you, your employer, and your client. Article by Ruth Roberts. SOAP NOTE 101. Soap Notes Example Massage. Client: Suzy Date: 2/1/15 Session #3. This task is easier if the nurse uses the problems to structure the SOAP note. This template is an example of a crisis note that I have made. A Take-Home Message. The following describes the requirements for social work progress notes. The following is an example of a SOAP note: Subjective. Title: Learning to Write Case notes Using the SOAP Format. She was binge drinking, but quit 2 years ago upon being advised that alcohol could worsen her health condition. Doctors and nurses use SOAP note to document and record the patient’s condition and status. Document the 5 Ws. Case Note Sample. Final decisions regarding the next steps to take, including dismissal from any further proceedings, should be noted in this section. Although she is asymptomatic, her blood pressure is 170/99 mmHg. For example, you might write that the client arrived 15 minutes late to the session and slouched in the chair. He will decrease depressive symptoms by engaging in positive social interactions 1x per week. SOAP stands for "subjective, objective, assessment, plan" – providing a standardized method of taking notes. into the format. SOAP notes were first developed in 1964 as a means of providing accurate records of a patient's history, case details, prognosis, treatment and results. This can be an issue when caseloads are demanding and face-to-face contact seems more important and/or satisfying. Case Note Template Social Work. The four parts are explained below. Case Note Example. Soap Notes Template. If you are required to write your … Continue reading → Posted in example, form, SOAP Notes | Leave a comment. Example: Produced /ch/ correctly in 17/25 (68%) initial sentences without any cues. SOAP is an acronym that stands for: S – Subjective O – Objective A – Assessment P – Plan. Case note templates available for immediate download. Note: Avoid general statements that seem vague. As a social worker, and you know what information needs to be provided in your note. Write the objective portion of the notes to include all factual information. Soap Case Notes Template. The SOAP note stands for Subjective, Objective, Assessment, and Plan. She enjoys writing on a variety of topics including children, education, gardening, pets, mental health and alternative medicine. SOAP NOTES You will write a SOAP note at the end of every session. 3. Download 28.50 KB #13. Generally speaking, a SOAP note is a short form organizing a patients personal and medical information and they are used primarily for admissions, medical history, and a few other documents in a patients chart. This can be used in later court proceedings to question the validity of the report. For purposes of comparison, an example of a HISTORY AND PHYSICAL (H/P) for that same problem is also provided. Share this: Email; Print; Pocket; Twitter; Facebook; Pinterest; Tumblr; LinkedIn ; Reddit; Related. The SOAP note is one of the few documentations used by health care providers. Medical History: Med Conditions: Asthma. Case Study Template. Apart from this, the DART form of note-taking notes is also an efficient way of recording the progress of a patient. For purposes of comparison, an example of a HISTORY AND PHYSICAL (H/P) for that same problem is also provided. Complete the subjective portion of the SOAP notes based on information obtained by the client. Leave no blank space between sections of the report and avoid writing in margins or adding additional information later on. Download 27.00 KB #14. Soap notes examples for social workers – medical documentation The last set of medical method of documentation examples that we have in hand is for social workers. Medical social workers are health professionals who work in hospitals, outpatient medical clinics, substance abuse treatment facilities and other health-care organizations. Free download Free Child Actor Resume Template Resume Fortthomas new from acting resume example professional with … Your client might get defensive upon hearing your assessment and start making excuses. They’re time-consuming and generally a drag to write. ♦ Example: Needs support in dealing with scheduled appointments and taking See more ideas about Soap note, Therapy tools, Clinical social work. While SOAP is a more popular format in medicine, the Data, Assessment, Plan paradigm is potentially more appropriate for behavioral health. What to avoid: Do not include general statements without supporting data. Take ibuprofen 600 mg p.o. SOAP Note for Coaching Sessions (PDF). Download 28.00 KB #18. He had great motivation and willingness to participate. Sample SOAP Note For Social Workers. Writing SOAP notes to accompany every session is one common and effective method for doing this. A SOAP note is a medical document used to present a patient’s information. The idea of a SOAP note is to be brief, informative, focus on what others need to know (e.g., doctors, nurses, teachers, OT, PT, social worker, another SLP, etc. The information is used for patient care. A SOAP note consists of four sections, namely: Subjective, Objective, Assessment and Plan. It helps for documentation purposes and they get shredded immediately after I type up my clinical case note. t.i.d. If I had to choose between a form of checklists filled out by anyone versus a single narrative written by a knowledgeable social worker, I’d choose the latter every time. Created Date: 8/14/2002 8:01:30 PM A SOAP note is a progress note that contains specific information in a specific format that allows the reader to gather information about each aspect of the session. Welcome to the first of a pair of articles about the basics of documenting hospice social work. Creating an effective DAP note example for therapy sessions doesn’t have to be a challenge. How to compose an excellent SOAP note is rather easy if you follow these correct steps. Through the use of each of the four areas in this record-keeping method, a social worker documents initial problems, steps taken to resolve the problem and the final results of these treatment steps. Each of these sections is employed for assessing the problems of the patient and furnishing him with a form of treatment. Today we’ll look at how to get the visit note done well. Care Notes Examples. The nurse would divide each section of the SOAP note according to these major issues, and address each in a paragraph. She is also obese and has hypothyroidism. Advertisement. A DAP note is a method of documentation used by health care providers, social workers and similar professionals. > Soap Notes Template Social Work. Chief Complaint: 23-year-old male presents w/ a chief complaint of: “my lower left back jaw has been sore for the past few days” History of Present Illness: Pt relates the history of swelling for past 3 days, asymptomatic previously. Date and Time session begins and ends and length of session, Any community support services needed or integrated into treatment, Stressors impacting treatment goals or progress. Tips for creating your DAP notes. Client’s Progress Note Template For Professional Counselors, SOAP Note Format for Mental Health Counselors, SOAP Note Examples for Mental Health Counselors, Clinically important statements made by client or family members attending session, Statements may refer to feelings, thoughts, actions, treatment objectives, concerns, Social worker may quote or summarizes clients statements, but does not assess or interpret statements in this section, Physical appearance: hygiene, sick, well, tired, alert, Assessment or understanding or hypothesis or synthesis of the S and O data, Client’s progress made in session insights and understanding, Family dynamics which impact client progress, How clients symptoms have decreased, increased or renamed the same, What the next steps are regarding treatment. Sample SOAP Note For … Process. Resume For Rn Case Manager. 2. In this article, we will discuss the fundamental of a SOAP note in general. The more skilled you are at writing case notes, the faster they will go. Soap Notes Template Counseling. Data includes subjective and objective information about the client, the clinical social worker’s observations, and the general overview of the session. How to compose an excellent SOAP note is rather easy if you follow these correct steps. Posted on August 4, 2015 by admin. This should focus on the problem that brought the client in contact with the social worker, how the client understands the problem, how it affects his life and what he hopes to find in regard to help or treatment. Clinical social workers are exempt from releasing psychotherapy notes without patient authorization, and psychotherapy notes also are excluded from the provision that gives clients the right to see and copy their health information. SOAP notes, are a specific format used for writing a progress note.This packet of 8 professionally created SOAP notes and Progress Notes can be downloaded and customized with your letterhead immediately.These notes were created for mental health care professionals: counselors, social workers, psychologists etc. This note is widely used in medical industry. DAP Note Examples. Here’s an example of a note for an imaginary client who expressed suicidal thoughts but was able to create a safety plan. Visit http s://www.ICANotes.com for a free trial or demo. A Take-Home Message. Dec 28, 2017 - See the Soap note example on our site and download our forms kit to use in your business. Their defensive reaction is worth noting. Patient will follow up in 2 months. Advertisement. SOAP -- Subjective, Objective, Assessment and Plan-- notes may be used by any medical professional, but each discipline uses terminology and other details relevant to the specialty.Nursing SOAP notes, for example, may use nursing diagnoses, while physicians' SOAP notes include medical diagnoses. Below is a template that I created for use for crisis sessions. Template Example. These are volunteers that are responsible to collect the data and assist the decision-makers in the healthcare institution. components. This may include information such as referrals to outside agencies or consultations needed by the social worker with another professional regarding the client. See more ideas about soap note, therapy tools, clinical social work. Download 26.50 KB #17. Title: Learning to Write Case notes Using the SOAP Format. Following the SOAP format ensures that you consistently document your patient’s current condition and progress in treatment. This involves taking the information provided in the first two sections and using it to draw a final conclusion on the problem and the needs of the client. The Basics of DAP. For the purposes of this sample progress note, the focus is on the content of the progress note, rather than the format. This information has to follow a specific format to make it easily understood by all members of the medical team. During ward rounds, medical personnel and students need to take notes about patients. Kristin Urbauer has been freelance writing since 2009 when she began publishing work for various websites. Numerous examples are given throughout. Case Note Format. They were created in Microsoft Word and are Windows and Macintosh … Health care providers, such as doctors, clinicians, physicians, and nurses as well as medical interns use a SOAP note to communicate effectively to their colleagues about the condition of the patient as it is essential when providing a cure for the diagnosis and giving medical or surgical treatment. Article by Ruth Roberts. Include your professional opinion in the assessment portion of the SOAP notes. It may include detailed observations about the client’s appearance, behavior, body language, and mood. More than just an assessment tool, the Social Work Assessment Notes (SWAN) is a patient-centered comprehensive documentation system that links assessment findings to the hospice plan of care across 9 psychosocial areas for hospice patients and their caregivers. Today, she has come for routine follow-up. Today, she has come for routine follow-up. The SOAP note is considered as the most effective and standard documentation used in the medical industry along with the progress note. Patient will follow up in 2 months. SOAP notes in the ambulatory care setting are often used to document patient interactions for billing pur-poses. May Quotes Soap Note Mental Health Counseling Therapy Worksheets Social Workers Notes Template Family Therapy Best Templates. SOAP Notes If you have ever ... For example, say your client tells you they have consumed alcohol a few times this week after work. Created Date: 8/14/2002 8:01:30 PM Forms are available for immediate download. Most mental health clinicians utilize a format known as SOAP notes. PROGRESS NOTE (GIRP FORMAT) Client will identify three triggers of substance use in order to reduce risk of relapse, and will increase control over cravings, as evidenced by using learned coping skills from 0 times per day to 3x per day. 19 likes. A DAP note is a method of documentation used by health care providers, social workers and similar professionals. The sample offers examples of what the SAPC QI and UM Write all SOAP notes in black pen for ease of reading and photocopying. Numerous examples are given throughout. Sample Note. A SOAP (subjective, objective, assessment, plan) note is a method of documentation used specifically by healthcare providers. Case Note Example Social Work. Soap Notes Example Psychotherapy. Having a long and an exaggerated SOAP note that does not follow the template. Pinterest. Record information during or immediately following meetings with the client to ensure accuracy of the records. > Soap Notes Template Social Work. 19+ SOAP Note Examples in PDF Health care providers, such as doctors, clinicians, physicians, and nurses as well as medical interns use a SOAP note to communicate effectively to their colleagues about the condition of the patient as it is essential when providing a cure for the diagnosis and giving medical or surgical treatment. ... Case Note Example Social Work. Soap Notes Template Social Work. The perfect examples of progress notes are SOAP. Copyright 2020 Leaf Group Ltd. / Leaf Group Media, All Rights Reserved. Avoid making judgments or using labels to describe the client. SOAP Note for Counseling Sessions (PDF). Data — this section includes observable and identifiable behaviors and traits. Reading → Posted in example, form, SOAP notes are used so staff can down... Of further inquiry or testing to guide proper treatment of the SOAP note is and why it is used Quotes... Note possible areas of further inquiry or testing to guide proper treatment of the medical along! … SOAP notes visit note done well know what information needs to be by. To write down information so that they have been drinking a lot,! Example: Produced /ch/ correctly in 17/25 ( 68 % ) initial sentences without any.... Like in ( semi ) real life write a SOAP note consists of four sections namely... Example of a pair of articles about the client, including dismissal from any proceedings... Progress note: Assisted Janea with grocery shopping, budgeting, making change, talking people! Is used electronic medical records follow a specific format to make it easily understood by all of... Pressure is 170/99 mmHg therapy tools, clinical social work progress notes are used to a. Pinterest ; Tumblr ; LinkedIn ; Reddit ; Related # 3 Figure out the patient ’ appearance... The ambulatory care setting are often used to document and record the progress of treatment and the! Writes in dismissal from any further proceedings, should be noted in article. General statements without supporting data proper treatment of the [ … ] 2 the simple note a! What to avoid: Do not include general statements without supporting data consistently document your patient ’ s record... Possible areas of further inquiry or testing to guide proper treatment of records! Example on our site and download our forms kit to use in your business quick way between. Easy if you follow these correct steps and record the progress of a HISTORY and PHYSICAL ( ). A template that I have made patient interactions for billing pur-poses complete the Subjective portion a... Will write a SOAP note, therapy tools, clinical social work case notes will protect you! Report and avoid writing in margins or adding additional information later on ) note is social work soap note example popular... Plan ) format and effective method for doing this, and your client or immediately following meetings the... Fictional example of a SOAP note: Subjective to understand what a SOAP ( Subjective, Objective, and... Has an emergency, she usually comes to the first of a note. Binge drinking, but quit 2 years ago upon being advised that alcohol could worsen health. Also an efficient way of recording the progress note requirements example # 1 Took Janea the! First, you must offer sufficient details ; writing the plan is final! Depressed mood and flat affect any danger to self or others and what the plan for addressing.! Mood and flat affect to include the 5 Ws: the who, what,,. That she has persistent suicidal thoughts but was able to create a safety plan s – O... Further inquiry or testing to guide proper treatment of the records and include whatever information an insurance company would to. Organized, and it includes the relevant interventions for the second example of SOAP... In treatment health-care organizations for more information about progress note, therapy tools, clinical social work is... Notes in the chair browser for the brave that want to venture into a similar template for themselves part the. % ) initial sentences without any cues in hospitals, outpatient medical clinics, substance abuse treatment and! Apart from this, the focus is on the content of the report efficient. A red flag for insurance claims reviewers a challenge interactions 1x per week might write the..., your employer, and mood post, we ’ ll tackle how to get the visit note done.! Health care providers, social workers, physicians, counselors and psychiatrists a custom case Study on SOAP note to! Detailed observations about the basics of documenting hospice social work understood by all of. Treatment and are the substance of a medical social worker, a patient may have heart,! For therapy sessions doesn ’ T have to understand what a SOAP note is considered the. Case Study on SOAP note example that want to venture into a similar social work soap note example for themselves condition and in... Objective portion of the notes to accompany every session is one of the few used..., budgeting, making change, talking with people, and include information... Soap ( Subjective, Objective, Assessment, plan paradigm is potentially appropriate! Chart or electronic medical records specific format to make it easily understood by all members of the notes accompany. The University of Nebraska where she majored in English should be noted in this browser for the second example a. For example, a patient ’ s chart or electronic medical records the session and slouched in chair head! Today we ’ ll look at how to compose an excellent SOAP and! Judgments or Using labels to describe the client to ensure accuracy of the SOAP format 5 Ws: the,...

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