Soap Note

[dentalgirl1]

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Just wondering if anybody has an
example of a good Dental Soap Note.
A speedy response would be greatly appreciated

 

[toofache32]

S: Pt says his tooth broke.
O: It did.
A/P: ext

 

[clickytop]

S: Pt says his tooth broke.
O: It did.
A/P: ext

I have to admit I'm a little disappointed. I clicked on this thread expecting to see a prison/shower joke.

 

[ShawnOne]

SOAP Notes

S: "I have a chipped tooth (several months ago) and it did not cause pain until Friday. Now, I have pain on cold and sweets and it is a moderate sharp pain that occurs and it is better when I take a couple advils. I can feel the area is swelled up, and when I press on the gum, I can feel it. The tooth is in the lower left." (First premolar). Pt filled out a Pain and Chief Complaint History documenting the type and quality of the current symptoms.
O: VITALS: BP: 120/78 RAS Pulse 64 reg Resp: 18 unlabored; Temp: 98.8 F
Reviewed Med Hx and entered into Axium. Clinical exam and Radiograph revealed fractured tooth of distal. Pt has swollen fluctuant buccal gingival tissue. Pt was unresponsive to percussion. Positive for bite test, lingering pain "at root.". Pt responded negative to vitality testing (CO2).
A: Pt has pulpal necrosis and chronic periradicular abscess.
P: Remove decay, identify canals and extirpate.
Anesthetized pt with 1.5 carpules 2% lidocaine w/ 1:100K epi for IANB and long buccal injections. Rubber Dam applied and #19-22 isolated. Occlusion reduced. Decay removed. Tooth accessed, canals identified. , extensive decay but initial evaluation seems tooth is restorable. Occlusion reduced. Decay removed and access completed. Canals identified. Radiograph length determined to be 18mm. #15 file inserted into canal and radiograph taken. Soft tissue debridement with #20, #25 files. Sodium hypochlorite irrigation. Canals dried with paper points. Chlorhexidine applied to the canal. Cotton pellet and cavit applied to tooth and pt strongly urged to get a root canal and crown at earliest convenience. It was stressed to pt to use OTC meds to relieve any pain in the interim. It was heavily stressed to the pt that this is a temporary tx and needs comprehensive evaluation at a later date.

 

[aphistis]

SOAP Notes

S: "I have a chipped tooth (several months ago) and it did not cause pain until Friday. Now, I have pain on cold and sweets and it is a moderate sharp pain that occurs and it is better when I take a couple advils. I can feel the area is swelled up, and when I press on the gum, I can feel it. The tooth is in the lower left." (First premolar). Pt filled out a Pain and Chief Complaint History documenting the type and quality of the current symptoms.
O: VITALS: BP: 120/78 RAS Pulse 64 reg Resp: 18 unlabored; Temp: 98.8 F
Reviewed Med Hx and entered into Axium. Clinical exam and Radiograph revealed fractured tooth of distal. Pt has swollen fluctuant buccal gingival tissue. Pt was unresponsive to percussion. Positive for bite test, lingering pain "at root.". Pt responded negative to vitality testing (CO2).
A: Pt has pulpal necrosis and chronic periradicular abscess.
P: Remove decay, identify canals and extirpate.
Anesthetized pt with 1.5 carpules 2% lidocaine w/ 1:100K epi for IANB and long buccal injections. Rubber Dam applied and #19-22 isolated. Occlusion reduced. Decay removed. Tooth accessed, canals identified. , extensive decay but initial evaluation seems tooth is restorable. Occlusion reduced. Decay removed and access completed. Canals identified. Radiograph length determined to be 18mm. #15 file inserted into canal and radiograph taken. Soft tissue debridement with #20, #25 files. Sodium hypochlorite irrigation. Canals dried with paper points. Chlorhexidine applied to the canal. Cotton pellet and cavit applied to tooth and pt strongly urged to get a root canal and crown at earliest convenience. It was stressed to pt to use OTC meds to relieve any pain in the interim. It was heavily stressed to the pt that this is a temporary tx and needs comprehensive evaluation at a later date.

Ahh, Axium. The system we use at the VA for medical records (CPRS) is pretty good, but the dental module (DRMP) makes me pine for the good old days of Axium at IUSD...

 

[scalpel2008]

S: Pt says his tooth broke.
O: It did.
A/P: ext

addendum:

A/P ext, implant

 

[yamazaho]

Time to bump this, I know this thread is old.


The clinic that I am working in still write our own charts, and my dental school used to use digital charts. I am not too thrilled to write out the SOAP note in detail but something more efficient. So please help me out, by showing me a better example of a note that doesn't require too much writing.

Much appreciated!!!!

 

[1992Corolla]

Time to bump this, I know this thread is old.


The clinic that I am working in still write our own charts, and my dental school used to use digital charts. I am not too thrilled to write out the SOAP note in detail but something more efficient. So please help me out, by showing me a better example of a note that doesn't require too much writing.

Much appreciated!!!!

I don't think it gets shorter than the post right before yours!

 

[yamazaho]

I don't think it gets shorter than the post right before yours!

Well let's face it, how often do you come around a patient with only a broken tooth and NOTHING else, except for emergency Tx.

Anyone else can offer some help...???

 

[1992Corolla]

Well let's face it, how often do you come around a patient with only a broken tooth and NOTHING else, except for emergency Tx.

Anyone else can offer some help...???

I think soap notes have a place, I didn't really like them in dental school for routine visits. I use them in OMFS residency as I round on patients, but I think they pertain better to a hospital setting. One can definitely can take bits and pieces from the SOAP note format though.

Subjective: Chief complaint. Short and simple, what the patient tells you initially and what they tell you after a few probing questions. OPINION.
Objective: What you find out as a clinician. Blood pressure, pulse, respirations, O2 sat (if you go this far). Exam: Tooth vitality, cold test, percussion, what you see. I usually start in the back. Oropharynx, uvula, palate, buccal mucosa, vestibules, tongue, FOM, alveolus, gingiva, teeth. Mark down pertinent + and document negative findings (medico-legally). FACTS
Assessment: Quick one sentence of what is going on. DIAGNOSIS
PLAN: What are you going to do about it. Make this systems based and hit each thing as a separate entity.

If this is a routine visit:
Lets say a patient comes in for a class II amalgam
S: Pt here for filling #30DO amalgam. No complaints.
O: BP 125/76 P: 78 (i assume you have done your oral cancer screening at the initial visit and it is documented in chart) soft and hard tissues WNL. Caries IP #30DO.
A: Patient here for filling #30DO
P: Administered 2 carps 2%lido 1:100K epi to R IAN and LB. Infiltrated with 4% articaine B and L to #30. Removed caries DO from #30 in usual manner. blah blah blah
NV: DO #4 amalgam


Maybe that is too much???? A dental office I worked at before wouldn't do a SOAP note, I think that might be overkill unless it is an emergency.

Most procedures were scribbles and not sentences. Something like this:

"Routine visit, admin 2 carps 2% lido 1:100k epi. #30 DO amalgam. NV: 6mo f/u. Then the note was done."

In residency as an intern I am required to write the most detailed note I can.
As I do medicine it is even more detailed. If I don't catch dry skin on the back of someone's thigh, the medicine attending will ask me f I thought that was important...since the patient is being admitted for syncope work-up...awkward.

Hope that helps.

 

[yamazaho]

I think soap notes have a place, I didn't really like them in dental school for routine visits. I use them in OMFS residency as I round on patients, but I think they pertain better to a hospital setting. One can definitely can take bits and pieces from the SOAP note format though.

Subjective: Chief complaint. Short and simple, what the patient tells you initially and what they tell you after a few probing questions. OPINION.
Objective: What you find out as a clinician. Blood pressure, pulse, respirations, O2 sat (if you go this far). Exam: Tooth vitality, cold test, percussion, what you see. I usually start in the back. Oropharynx, uvula, palate, buccal mucosa, vestibules, tongue, FOM, alveolus, gingiva, teeth. Mark down pertinent + and document negative findings (medico-legally). FACTS
Assessment: Quick one sentence of what is going on. DIAGNOSIS
PLAN: What are you going to do about it. Make this systems based and hit each thing as a separate entity.

If this is a routine visit:
Lets say a patient comes in for a class II amalgam
S: Pt here for filling #30DO amalgam. No complaints.
O: BP 125/76 P: 78 (i assume you have done your oral cancer screening at the initial visit and it is documented in chart) soft and hard tissues WNL. Caries IP #30DO.
A: Patient here for filling #30DO
P: Administered 2 carps 2%lido 1:100K epi to R IAN and LB. Infiltrated with 4% articaine B and L to #30. Removed caries DO from #30 in usual manner. blah blah blah
NV: DO #4 amalgam


Maybe that is too much???? A dental office I worked at before wouldn't do a SOAP note, I think that might be overkill unless it is an emergency.

Most procedures were scribbles and not sentences. Something like this:

"Routine visit, admin 2 carps 2% lido 1:100k epi. #30 DO amalgam. NV: 6mo f/u. Then the note was done."

In residency as an intern I am required to write the most detailed note I can.
As I do medicine it is even more detailed. If I don't catch dry skin on the back of someone's thigh, the medicine attending will ask me f I thought that was important...since the patient is being admitted for syncope work-up...awkward.

Hope that helps.

Thanks dude. Yeah I decided to write up something simpler like the ones you posted. I do put down whatever detail I can remember, just in case I need them for whatever reason.

 

[OffAngleHatchet]

I am not too thrilled to write out the SOAP note in detail but something more efficient. So please help me out, by showing me a better example of a note that doesn't require too much writing.

This is pretty much verbatim from one of my emergency patients today. I still do fairly detailed SOAP notes, but I save time by sticking to standard (for me) abbreviations:

D0140 - T3
D9951 - OCCL ADJ (LIM)
S: PP w CC: "My tooth hurts @ UL" BP: 128/80@72bpm, T: 98.2F
MHX: HQR DTD 3/21/11, NSF, NKDA, no MEDS, pain 6/10 on bite, cold (NL). DHx: #15-MO alloy placed 2/14/11.

O: RE: PA #14,15 - NSF, no PARLs
EOE: NSF
IOE: Hvy occl #15 @ triangular ridge
VT: Perc (+), Cold (++, NL, 5 sec), EPT(+)
A: #15 - 1 Traumatic Occl, rev pulpitis
P: TOT, PID, PVU. DWP: Pain due to hyperocclusion. Anes: PSA #15 (1/2 carp 2% lido, 1:100K epi). Occl adj #15 to pt comfort. Occl V.
NV: RDH

Translation:


D0140 - Emergency Exam
D9951 - Occlusal Adjustment (Limited)
S: Patient presents with Chief Complaint: "My tooth hurts in the upper left" Blood Pressure: 128/80 at 72 bpm, Temperature: 98.2F
Medical History: Health Questionnaire dated 3/21/11, no significant findings, no known drug allergies, no meds. Pain rated 6/10 on biting, and cold (non-lingering)
Dental History: #15-MO alloy placed 2/14/11
O: Radiographic Exam: PA #14,15 - no significant findings, no periapical radiolucencies.
Extraoral Exam: No significant Findings
Intraoral exam: Heavy occlusion on #15 at the triangular ridge
Vitality Test: #15 - Tests positive for percussion, Cold (moderate pain response, non lingering, duration 5 seconds), Electronic Pulp Test positive
A: #15 Primary traumatic occlusion , reversible pulpitis
P: Time out Taken, Patient ID Verified, Patient Verifies Understanding. Discussed with patient - pain due to hyperocclusion. Anesthesia: PSA for #15, 1/2 carp lidocaine with 1:100K epi). Occlusal adjustment of #15 to patient comfort. Occlusion checked.
Next Visit - Hygiene.

Forgot to add: one good habit I retained from dschool is to list the CDT codes before even starting the SOAP note... It really helps out when you're trying to quickly assess the dental history of a patient.

 

[OffAngleHatchet]

Maybe that is too much???? A dental office I worked at before wouldn't do a SOAP note, I think that might be overkill unless it is an emergency.

Most procedures were scribbles and not sentences. Something like this:

"Routine visit, admin 2 carps 2% lido 1:100k epi. #30 DO amalgam. NV: 6mo f/u. Then the note was done."

Just from observing different offices,it seems like the older generation of dentists tend to stick with the one-liners, rather than do a full SOAP or abbreviated SOAP. It's the younger dentists who tend to do things more in SOAP format, probably a reflection of how things have shifted in dental education over the years. SOAP notes were drilled into us @ Pacific as a way to cover our asses in case something went awry or someone complained.

 

[1992Corolla]

Just from observing different offices,it seems like the older generation of dentists tend to stick with the one-liners, rather than do a full SOAP or abbreviated SOAP. It's the younger dentists who tend to do things more in SOAP format, probably a reflection of how things have shifted in dental education over the years. SOAP notes were drilled into us @ Pacific as a way to cover our asses in case something went awry or someone complained.

Interesting as these quick one sentence progress notes were written by the younger generation.👍

 

[setdoc7]

Quick one line chart posts are okay until someone asks you for the chart to review (lawyer, ins co, peer review). Then you wish the notes were longer and more detailed. A word to the wise.