S.0.A.P.

Prepared by: Dr. Maria Luisa Ramos-Clemente

All healthcare professionals document
what they do to their patients.
One of the methods they use is a form
of patient care note called S.O.A.P.
S.O.A.P. Note

Is a highly structured and organized

format for documenting the progress
of a patient during treatment and is
only one of many possible formats that
could be used by a health professional.
S.O.A.P. is an acronym for:

SUBJECTIVE - are symptoms the

patient verbally expresses or as stated
by a significant other
OBJECTIVE- results of measurements
performed and the dentist's objective
observations
ASSESSMENT- diagnosis of the
patient's condition

PLAN - is the dentist's treatment plan

for the patient
 Lesson 1:
Origin, Purposes and Guidelines
in Doing S.O.A.P.
Origin
Origin:

The Soap note format was introduced

by Dr. Lawrence Weed in 1960 at the
University of Vermont, as part of a
system of organizing the medical
record called the problem-oriented
medical record (POMR)
Problem-Oriented Medical Record

POMR is a way of recording patient

health information in a way that’s easy
for physicians to read and revise.
Origin:

The POMR has one list of patient

problems in front of the chart and
each healthcare practitioner writes a
separate SOAP note to address each of
the patient’s problems.
Purposes of Documentation
All healthcare professionals document
their findings for several reasons:
 Purposes of Documentation:

1. Notes record what the therapist does to

manage the individual patient’s case. The
rights of the therapists and the patient are
protected should any question occur in the
future regarding the care provided to the
patient. SOAP is considered legal documents,
as are all parts of the medical record.
 Purposes of Documentation:

2. SOAP is a method of communication

with the patient’s physicians and all
other health care professionals,
including other therapists and
therapist’s assistants.
The note communicates the result of
the interview, the objective
measurements done and the other
therapist’s assessment of the patient’s
condition. It communicates the
treatment plan for the patient.
The goal of such communication is to
provide consistency between services
provided by the different healthcare
providers.
 Purposes of Documentation:

3. Third party payers, like Medicare and

other insurance company, make
decisions about reimbursement based
on therapy notes. These decisions can
be greatly influenced by the quality and
completeness of the notes.
 Purposes of Documentation:

4. Decisions on whether the patient is

ready to be discharged are based on the
notes written by the clinician.
Guidelines in Writing SOAP
Guidelines in Writing SOAP:

1. Accuracy
2. Brevity
3. Clarity
4. Correcting Errors
5. Signing your Notes
Guidelines in Writing SOAP:
1. ACCURACY
never record falsely, exaggerate, or
makeup data.
SOAP notes are part of a permanent,
legal document.
Objective information should be stated
in a factual manner.
Guidelines in writing SOAP:
2. BREVITY
information should be stated concisely.
Use short, succinct sentences.
Avoid long-winded statements.
Abbreviations can help with brevity.
Abbreviations used should be from the
accepted list of hospital abbreviations.
Guidelines in writing SOAP:

3. CLARITY
The wording of the SOAP notes should
be such that the meaning is
immediately clear to the reader.
Guidelines in writing SOAP:

4. CORRECTING ERRORS
Correction fluid/tape should not be
used on the medical record.
Trying to destroy or attempting to
obliterate information makes it look
like as if the health professional is
trying to “cover up” malpractice.
Guidelines in writing SOAP:

The proper method of correcting a

mistake made in charting is to put a
line through the error, write "error"
above the mistake, date it, and put
your initials.
Guidelines in writing SOAP:
5. SIGNING YOUR NOTES
You should sign every entry that you
make into the medical record.
All notes should be signed with your
legal signature.
Initials should follow your name
indicating your status.
 Lesson 2:
Structures of S.O.A.P.
STRUCTURES OF SOAP:

Subjective
Objective
Assessment
Plan
SUBJECTIVE

Is the first heading of the SOAP note.

This section includes a statement,
preferably the patient’s own words
regarding chief complaint which details
why the patient presented to the
health care facility.
SUBJECTIVE

The SUBJECTIVE part of the note is the

section in which the examiner is able
to state the information received from
the patient that is relevant to the
patient’s condition.
SUBJECTIVE

Subjective signs and symptoms

presented by the patient will
determine the line of inquiry that the
examiner must take in order to arrive
at a diagnosis.
Components of SUBJECTIVE Section:

A. CHIEF COMPLAINT
B. HISTORY OF PRESENT ILLNESS
C. PAST MEDICAL HISTORY
D. REVIEW OF SYSTEMS
E. FAMILY HISTORY
F. PERSONAL AND SOCIAL HISTORY
G. CURRENT MEDICATIONS AND ALLERGIES
A. CHIEF COMPLAINT
These are symptoms in the patient’s
own words relating the presence of an
abnormal condition.
It states the reason why the patient is
seeking consultation.
A chief complaint or presenting
problem is reported by the patient.
A. CHIEF COMPLAINT

Common complaints are pain, swelling,

difficulty in mastication, esthetic and
psychogenic complaints, dryness of mouth,
etc.
This can be a symptom, condition, previous
diagnosis, or another short statement that
describes why the patient is presenting
today.
B. HISTORY OF PRESENT ILLNESS

The chronological account of the CHIEF

COMPLAINT and associated symptoms
from the time of onset to the time of
consultation.
Taking the history is the most important
part of the patient examination.
B. HISTORY OF PRESENT ILLNESS

It serves as a foundation not only for

an intelligent approach to diagnosis
but also for the establishment of a
successful patient-dentist relationship.
This is the section where the patient
can elaborate on their chief complaint.
B. HISTORY OF PRESENT ILLNESS

An acronym often used to organize the

HPI is termed “OLDCARTS” (onset,
location, duration, characterization,
alleviating factors, radiation, the time
factor, and severity).
Importance of taking the case history:

1. To arrive at a tentative diagnosis of

the patient’s chief complaint.

2. To determine any systemic factor that

might affect the formulation of a
diagnosis.
3. To determine any systemic condition
that requires special precautions prior to
any dental procedures to protect the
health of the patient.
C. PAST MEDICAL HISTORY

Includes all information which reveals

the patient’s general health prior to
the onset of the present illness.
C. PAST MEDICAL HISTORY

The medical history considers such

things as past systemic diseases,
injuries and operations, which may be
related directly and indirectly to the
dental treatment.
C. PAST MEDICAL HISTORY

Medical history: Pertinent current or

past medical conditions

Surgical history: Try to include the year

of the surgery and surgeon if possible.
D. REVIEW OF SYSTEMS

Organized review of some apparently

unrelated symptoms.

It decreases the possibility of

overlooking important symptoms by
including other areas of the body.
D. REVIEW OF SYSTEMS

It gives the examiner logical sequence

for a complete review of the patient’s
history.
D. REVIEW OF SYSTEMS

is an inventory of the body systems

that are obtained through a series of
questions to identify signs and/or
symptoms that the patient may be
experiencing.
D. REVIEW OF SYSTEMS

It recognizes part of the systems such

as eyes, ears, nose, mouth, throat,
cardiovascular, Respiratory,
Gastrointestinal, Genitourinary,
Musculoskeletal, Integumentary,
Neurological, Psychiatric, Endocrine,
Hematologic/Lymphatic, Allergic/
Immunologic.
D. REVIEW OF SYSTEMS

It gives the examiner logical sequence

for a complete review of the patient’s
history.
Complete review of the patient’s history:

Head: headaches
Eyes: presence of unexplained redness or
inflammation
Ears: Tinnitus or deafness which can be
associated with drugs such as Salicylates;
mercury or quinine; history of vertigo
Complete review of the patient’s history:

Nose: epistaxis/nasal hemorrhage which

may be related to HPN or blood
dyscracias; sinusitis which may bring
about referred dental pain; colds
brought about by mouth breathing
which can cause gingivitis or dry mouth
Complete review of the patient’s history:

Throat: persistent hoarseness

Cardiorespiratory: symptoms such as
chest pain, dyspnea, ankle edema, and
cough should be explored due to its
relation to cardio-vascular and
pulmonary disease.
If the patient is unaware of his
condition but presents such symptoms
then it is best to refer the patient first
for further evaluation.
Complete review of the patient’s history:

Gastrointestinal: symptoms such as

anorexia, dysphagia, nausea, vomiting,
constipation, diarrhea, and jaundice may
be referable to the oral cavity.
Complete review of the patient’s history:

Genitourinary: disturbances to urinary

function may be a manifestation of
metabolic disorders such as DM.
E. FAMILY HISTORY

Gives information regarding the

family’s general health, history of
mental disease, history of chronic
infection in the family, cause of death
of parents.
F. PERSONAL AND SOCIAL HISTORY

An acronym that may be used here is

HEEEEADSS which stands for Home
and Environment; Education,
Employment, Eating; Activities; Drugs;
Sexuality; and Suicide/Depression.
F. PERSONAL AND SOCIAL HISTORY

Marital status: duration and health of

partners, pregnancies and number of
children
Habits: use of drugs, alcohol, tobacco
Occupation: exposure to occupational
hazards, financial status of patient
F. PERSONAL AND SOCIAL HISTORY

Weight: recent loss or gain of weight

with possible causes
G. CURRENT MEDICATIONS AND
ALLERGIES
OBJECTIVE

The OBJECTIVE part of the note is the

section in which the results of
measurements performed and the
therapist’s objective observations of
the patient are recorded.
OBJECTIVE

Objective data are the measurable or

observable information used to plan
patient treatment.
The testing procedures that produce
objective data are repeatable.
OBJECTIVE

Refers to data gathered by the

examiner during clinical examination.
OBJECTIVE

This section outlines the objective

observations, which means factors
that can be measure, see, hear, feel or
smell.
Components of OBJECTIVE Section:

A. VITAL SIGNS
B. CLINICAL EXAMINATION
C. LABORATORY RESULTS
D. IMAGING RESULTS
E. OTHER DIAGNOSTIC DATA
A. VITAL SIGNS

Pulse Rate
Respiration Rate
Temperature
Blood Pressure
B. CLINICAL EXAMINATION

Extra-oral Examination
Intra-oral Examination
B. CLINICAL EXAMINATION
Extra-oral: general appraisal of the
patient, which includes vital signs
(temperature, pulse rate, respiration
rate, blood pressure)
Head: asymmetries, deformities
Neck: lymphadenopathy, lesions and
tenderness
Jaws: TMJ
B. CLINICAL EXAMINATION

Intra-oral

Lips, Labial and buccal mucosa, Palate,

Oropharynx, Floor of the mouth,
Tongue, Teeth and Periodontium
Principles used in CLINICAL
EXAMINATION:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
C. LABORATORY RESULTS

 CBC
 Urinalysis
 ECG, etc.
D. IMAGING RESULTS

X-ray
CT scan
MRI
E. OTHER DIAGNOSTIC DATA
ASSESSMENT

Formation of a diagnosis or differential

diagnosis

DIAGNOSIS is the identification of a

disease by an investigation of signs and
symptoms.
DIFFERENTIAL DIAGNOSIS is the
determination by systematic
comparison and contrast of symptoms
of several diseases from which the
patient can be suffering from.
ASSESSMENT

Potentially the most important legal

note because this section documents
the synthesis of “subjective” and
“objective” evidence to arrive at a
diagnosis.
ASSESSMENT

This is the assessment of the patient’s

status through analysis of the problem,
the possible interaction of the
problems, and changes in the status of
the problems.
Elements of ASSESSMENT Section:

A. PROBLEM
A problem is often known as a
diagnosis.
Is the identification of the nature of an
illness or other problem by
examination of the symptoms.
Elements of ASSESSMENT Section:

B. DIFFERENTIAL DIAGNOSIS
This is a list of the different possible
diagnoses, from most to least likely, and
the thought process behind this list.
This is where the decision-making
process is explained in depth.
PLAN
The last section of a SOAP note is the
plan, which refers to how you are
going to address the patient’s
problem.
This section details the need for
additional testing and consultation
with other clinicians to address the
patient's illnesses.
PLAN

It also addresses any additional steps

being taken to treat the patient.
Presentation of an ideal or alternative
treatment plan
Includes description of the procedures
done
PLAN

POIG (Post-Op Instructions Given)

POMG (Post-Op Medications Given)
Follow-up
Factors Included:

Therapy needed (medications)

Specialist referral or consults
Patient education, counseling
References:

 https://www.ncbi.nlm.nih.gov/books/NBK482263/
 https://www.physio-pedia.com/SOAP_Notes
 Workbook in Hospital Dentistry 1. (2019 edition). East Ave Medical Center
Subjective

 (What the patients tells you) are symptoms the

patient verbally expresses or as stated by a
significant other, it may include any or all of the
following section: CC, HPI, PMH, FH, SH, ROS
Objective

 (What you see) Should NOT contain anything the

patients told you, note only objective
observation.
 You will record your physical findings, laboratory
diagnostic test results, age, general appearance,
vital signs (Temp, BP, RR, HR), findings from
system examination (eyes, ears, nose, throat,
cardiac and respiratory).
Assessment

 (What you think is going on based on subjective

and objective information) based on information
gathered from Subjective and Objective sections.
 To decide what you think is going on with the
patient.
 It could include more detailed information like
differential diagnosis and list of billable medical
diagnosis.
Plan

 (What you are going to do about it all) To decide

what to do, treatment plan for the patient.
 Include ordering or requesting consultation,
prescription, treatment and diagnostic like chest
x-ray, patient education, directions regarding
follow up.