SOAP

S = Subjective

O = Objective

A = Assessment

P = Plan


Subjective

Chief Complaint (CC)

  • Brief statement from patient.
  • Include patient's actual words.

History of Present Illness (HPI)

  • Describe current condition in narrative form.
  • Describe in patient's own words.
  • OLD CHARTS mnemonic
    • Onset (when did it start; what made it start)
    • Location (where is it)
    • Duration (how long does it last)
    • Character (sharp, dull, etc)
    • Alleviating/aggravating factors (hot, cold, biting, etc)
    • Radiation
    • Temporal pattern (when; getting better or worse; variable, constant, episodic, etc)
    • Symptoms associated

Objective

Vital signs

Extraoral exam

Intraoral exam

Radiographic exam

Laboratory and diagnostic tests

Assessment

Diagnoses

  • Periodontal
  • Dental (for every tooth that has a condition)
  • Intraoral structure
  • Using master problem list style is helpful
  • Include any differential diagnoses, in order of most likely to least likely.

Prognosis

Plan

Treatment plan for each item with a diagnosis in the Assessment section will be treated.

Referrals

Medications

Follow-up treatment recommended

 


General comments about SOAP