S = Subjective
- Opinion; what the patient reports.
O = Objective
- Fact; what the doctor finds during physical exam.
A = Assessment
- Conclusions; doctor's diagnosis and prognosis.
P = Plan
- Action; what doctor will do.
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)
- Temporal pattern (when; getting better or worse; variable, constant, episodic, etc)
- Symptoms associated
Laboratory and diagnostic tests
- 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.
Treatment plan for each item with a diagnosis in the Assessment section will be treated.
Follow-up treatment recommended
General comments about SOAP
- Abbreviations may be used, but only use abbreviations that would be commonly understood by anyone in the dental field.
- A SOAP entry should be legible and understandable if read by another staff member, another dentist, insurance company, malpractice insurance company, or attorney.
- Each SOAP entry should be signed by the actual person making the entry.
- See "Periodontal Assessment and Treatment Planning" for items that could be included in Objective section.
- See "Classification System for Periodontal Diseases" for examples of items that could be included in Assessment section.
- See "Oral Pathology Disease List" for examples of items that could be included in Assessment section.
- These forms might accompany a SOAP entry:
- A SOAP entry does not necessarily take the place of a more detailed progress notes or clinical notes entry.
- Avoid asking the patient "yes" or "no" questions when discussing Subjective items.