SOAP notes

Subjective

S, what the patient tells you

Objective

O, What you see/measure

Assessment

A, what you conclude

Plan or procedure

P, what will you do

Subjective

WHAT PATIENT TELLS YOU

Includes chief concern, history of chief concern (CC), medical history (MH), dental history (DH), social history (SH)

Symptoms:

- pain, where, when, relievers

Esthetic concerns

Fears and feelings about treatment

Objective

WHAT ARE YOUR OBSERVATIONS/MEASUREMENTS

Includes Physical exam (PE)/Vital Signs (VS), Extraoral exam (EOE), Intraoral exam (IOE), summary of appearance of both soft (perio) and hard tissue exams (HTE), and radiographic exam (RE)

Signs (as opposed to symptoms)

- swelling, fractured cusp/exposed dentin, carious legion, peri-apical radiolucency in radiography

Assessment

WHAT IS YOUR DIAGNOSIS/CONCLUSION?

Based on S and O what to include?

- Perio DX: periodontal diagnosis and risk assessment

- CRA: caries diasease diagnosis and risk assessment

- Occlusion/TMJ assessment

- Restor Dx: restorative needs, surgical and non surgical

Know etiology (cause of all above) and come up with prognosis (ideal outcome of treatment)

Perio Dx

Periodontal diagnosis and risk assessment

CRA

Caries disease diagnosis and risk assessment

Restor Dx

Restorative needs, surgical and non-surgical

Etiology

cause of disease

Prognosis

Ideal outcome of treatment

Plan

WHAT TREATMENT WILL YOU PROVIDE?

Includes notes on:

- treatment plan discussion (be detailed)

= procedures

- instructions, recommendations, referrals

- Perscriptions (DWP, RBA, ABC)

DWP

discussed with patient

RBA

Risk and benefits of alternatives

ABC

Alternatives with benefits and complications

If treatment was not performed

details of discussion (DWP) proposed treatment with options and referrals

If treatment was performed

Step by step details of clinical procedure, what where how much anesthetic, type and quality of materials used, details of perspectives (drugs, mg, tabs, DWP)

Subjective

Objective

Assessment

DX: diagnoses of treatment conditions

Plan/procedure

Date, procedure code, who made entry

Each SOAP note must contain

Don't

Do/Dont: alter or destroy information or "cover up"

diagnostic or treatment errors

Do

Do/Dont: correct documentation errors in a written record

by putting a single line through the error and make

correction above with the date and your initials

Do

Do/Dont: correct such errors in our electronic record by a

new entry which records the student provider and

attending faculty with the date when error corrected