The SOAP Note is a format of writing medical records that started in physician’s offices, but was quickly adopted into the dental field. Do you work in a practice that requires using the SOAP Note technique? If not, give it a try. Let's break it down.
SOAP is an acronym- Subjective, Objective, Assessment, and Plan. This system was created to help prevent charting mistakes or information from being left out. Just like each patient is unique, each chart in unique with information and length of notes.
Here is an example what each letter of SOAP includes:
This section starts with the chief concern of the patient and any reported symptoms, such as when the pain started, how long it’s been happening, when and where the pain happens, etc. This section also includes health history notes of a new patient and health history updates on current patients.
This next section tells about the patients current health- blood pressure reading, extra and intra oral exam findings, which radiographs were exposed and findings based on them, any mobility or furcations, any symptoms to in office testing like percussion or cold tests, gingival descriptions, and a brief description of periodontal probing findings.
This is where the dental hygiene diagnosis is recorded based on all previous findings.
Now we finish off with the treatment plan that needs to be carried out. In dental hygiene this could be completed at that day or over several appointments.
If you decide to use SOAP Note technique or if your office requires it, I’d recommend adding a few more letters to the acronym. Since hygiene appointments include so much information, use SOAP-TOPE. It’s definitely not as catchy, but it includes a little more information that we need.
In hygiene, many appointments have us diagnosing, treatment planning, starting and finishing treatment all in the same day. Here you would include what treatments were completed at that appointment- full mouth prophy, fluoride, radiographs, and periodontal debridement quads with what anesthetic and how much was used.
O- Oral Hygiene Education
Here we would chart current habits, goals made, products recommended, and techniques taught at that appointment. Explanation of periodontal health and the importance of regular recall appointments would be written here too.
P- Personal Notes
Jot down just a few notes of what you talked about with your patient that appointment. It could be an upcoming trip, work or school information, family happenings, or important events coming up. This will make the next appointment in 6 months more personal for both the patient and you. Building meaningful relationships with patients is one of the best parts of dental hygiene!
Chart everything the dentist talks about with the patient. And I mean EVERYTHING! Of course, we always chart restorations that need to be completed, but be sure to chart conversations on whitening, night guards, headaches, areas to be watched, or any other possible treatment options that could be brought up in the future.
Real Life Example of SOAP-TOPE:
S: Patient is interested in whitening options. No toothaches or sensitivity today.
0: No changes to medical history per patient. Blood Pressure: 124/74. Healthy bone levels visible on radiographs, with generalized 1-3mm pocketing (see perio chart). Localized BOP on buccal of 2, 3, and 4. No mobility or furcations present.
A: Generalized healthy with localized marginal gingivitis due to pt missing brushing area.
P: Adult prophy, FL2 Tray
T: Adult prophy hand scale only- patient did not tolerate ultrasonic well. Polish with fine paste. Floss. APF FL2 tray placed for 1 minute with post op instructions of no eating or drinking for 30 mins. Pt agreed to post op ins.
O: Brush 1x day. Floss 1x day. Explained to patient area on buccal of 2, 3 and 4 that presented with heavy biofilm. Recommended pt close partially to brush that area, or switch to a smaller head toothbrush. Goal: Start brushing on the buccal of Quad 1 each time he brushes. Explained whitening procedures and post op sensitivity that may occur. Recommended at home FL2 treatment of Clinpro 5000 to prevent sensitivity. Disp: Soft TB, Glide Floss, Sensodyne Samples
P: Pt is getting married next month which is why he is interested in whitening. Wedding will be held at his grandparent’s farm. Met his fiancé in college.
E: Per Dr. Harris: Decay present #3-O, #14-DO. Explained Zoom Whitening to patient, procedure, cost, and post op pain and instructions.
Great charting habits will make your life, your dentist’s life, and your office manager’s life flow much smoother. Try out the SOAP-TOPE charting method and see how it works for you!