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the purpose of the patients dental visit
description of symptoms in the patients OWN

words: Onset Chronology Quality Severity Modifying Factors Additional Symptoms Treatment

Example: Patient presents complaining of missing tooth #7. States that the tooth was extracted after an unsuccessful attempt at restoration. Past medical history is non-contributory, however patient admits to smoking 1/2 pack per day of cigarettes. Past dental history: Patient receives dental cleanings irregularly, does not use floss.


Clinicians Examination
Documents objective, repeatable, and traceable facts

about the patients status

Vital signs Findings from physical examinations Results from laboratory Measurements

Example: Intra-oral exam reveals tongue, palate, FOM WNL. Gingiva is pink and stippled with localized swelling and redness in lower anterior and maxilla posterior regions. Pocketing and dentition as charted (see charting). Missing tooth #7. Adjacent teeth #6, 8 show slight drifting into space of #7. Slight plaque, moderate stain. Slight stick to explorer in occlusal pits maxillary premolars, however bite-wing radiographs reveal no sign of decay. #31 with large IRM. Radiographic exam reveals IRM #31 is close to pulp. Bone loss seen in area of #23-26.

the diagnosis of the patients condition done by the

diagnosis may be clear or there may be several

diagnostic possibilities.


1) Missing #7 2) Localized periodontal disease #23-26 3) #31 restoration close to pulp, poss. pulpal pathology 4) Max. premolars non-carious

proposed treatment Plan may include:

ordering labs referrals procedures performed medications prescribed patient follow-up care instructions etc.


Today: Examination, full mouth series radiographs taken and read. Alg. imps for study 1) Explained to patient that there are several different ways to restore missing #7. Will review study casts and discuss options and fees at next appointment.

2)Expl'd to patient need for more frequent prophys, and the use of floss.

3)Will evaluate pulpal status of #31 with endodontic consult

4)Recommend no treatment for occlusal fissures of premolars RTC (Return to clinic) Discuss treatment plan options.

SOAP format
their credentials

the usage of abbreviations is standard

individual making the notation sign their name and list

If an error is made, a single line should be drawn through

the error, dated and initialed, and the correction written.

be written fluently and without blank lines between the