SOAP Note

Question 1

What does S in SOAP mean?

Answer 1

S= subjective, what did they say?, chief complaint, health/dental history, recent treatments, recare intervals, last known radiographs and exam, med alerts, allergies, patient notes (stressed, worried, hate the dentist, etc.)

Question 2

What does O in SOAP mean?

Answer 2

O= objective, what did you observe or measure?, ASA, vitals, EO/IO, occlusion, gingival description, bleeding, restorative, perio exam, calculus and plaque levels, radiographs, indices

Question 3

What does A in SOAP mean?

Answer 3

A= analysis, what does it mean?, perio classification (ADA, AAP), caries risk level, perio risk level, oral cancer risk, DH diagnosis, contributing factors, constraints: what types of things prevent the desired outcome?, therapy outcome: prognosis, what outcome do you expect from tx?

Question 4

What does P in SOAP mean?

Answer 4

P= plan, what do you plan to do?, tx plan including anticipated cost, home care instruction, signatures, anticipated recall, referrals, recommendations: sports guard, whitening, etc., evaluation of previous therapy

Question 5

Therapy Evaluation

Answer 5

1. Pertinent dental history
2. What do you see today?
3. Interventions/plan
4. Prognosis