How to Properly Write a SOAP Note 

How to Properly Write a SOAP Note

A SOAP note (Subjective, Objective, Assessment, Plan) is a structured method for recording patient information and ensuring clear, concise, and accurate documentation. In a dental office, properly written SOAP notes are essential for maintaining patient records, aiding in diagnosis, and supporting claim submissions with strong narratives.

Breaking Down the SOAP Note:

1. Subjective (S):

   • This section captures the patient's verbal complaints, concerns, or symptoms. It is crucial to document the patient’s own words accurately, as this provides context for the dental visit.

   • Example: "Patient reports sensitivity in the upper right molar when consuming cold beverages."

2. Objective (O):

   • Record measurable or observable data. Include clinical findings from the examination, radiographs, or other diagnostic tools.

   • Example: "Decay noted on tooth #3, with visible enamel breakdown and radiographic evidence of dentinal involvement."

3. Assessment (A):

   • Document the diagnosis or possible diagnoses based on subjective and objective findings. Be specific and use proper terminology.

   • Example: "Caries on tooth #3, symptomatic."

4. Plan (P):

   • Outline the proposed treatment, recommendations, or next steps. Include patient education and follow-up instructions.

   • Example: "Recommended treatment: Composite restoration for tooth #3. Informed patient of procedure, benefits, and risks. Obtained consent. Scheduled treatment for 12/15/2024."

Importance of SOAP Notes for Claim Narratives

A well-documented SOAP note can help craft a detailed and accurate narrative to accompany insurance claims. This ensures that the claim is supported by sufficient evidence and justifies the necessity of treatment, reducing the likelihood of denials.

Sample SOAP Notes and Narratives for Claims:

1. Scenario: Crown Replacement

• SOAP Note:

  • S: Patient reports discomfort with existing crown on tooth #19 and food trapping.

  • O: Clinical examination reveals marginal leakage on the crown of tooth #19. Radiograph shows recurrent decay beneath the crown.

  • A: Recurrent caries under existing crown on tooth #19.

  • P: Recommended crown replacement. Discussed findings with the patient. Obtained consent. Scheduled crown prep for 12/20/2024.

• Narrative: "Patient presented with discomfort and food trapping around an existing crown on tooth #19. Clinical and radiographic examinations revealed marginal leakage and recurrent decay beneath the crown. Treatment plan includes crown replacement to restore form and function."

2. Scenario: Scaling and Root Planing

• SOAP Note:

  • S: Patient reports bleeding gums and sensitivity during brushing.

  • O: Periodontal charting indicates 5-6 mm pocket depths in posterior sextants with bleeding on probing. Radiographs show horizontal bone loss.

  • A: Generalized moderate chronic periodontitis.

  • P: Scaling and root planing recommended for affected quadrants. Reviewed oral hygiene techniques with the patient. Scheduled first session for 12/18/2024.

• Narrative: "Patient presented with bleeding gums and sensitivity. Clinical examination revealed 5-6 mm pocket depths with bleeding on probing and radiographic evidence of horizontal bone loss. Diagnosis: generalized moderate chronic periodontitis. Treatment involves scaling and root planing to reduce pocket depths and improve periodontal health."

3. Scenario: Extraction

• SOAP Note:

  • S: Patient complains of severe pain in lower right molar for the past week, unresponsive to over-the-counter pain medication.

  • O: Tooth #31 has a large fracture with pulpal exposure and extensive decay. No restorability noted. Periapical radiograph confirms periapical abscess.

  • A: Non-restorable tooth #31 with periapical abscess.

  • P: Extraction recommended to alleviate pain and infection. Discussed risks and benefits with the patient. Obtained consent. Scheduled extraction for 12/14/2024.

• Narrative: "Patient presented with severe pain in the lower right molar, unresponsive to OTC pain relief. Examination revealed a large fracture with pulpal exposure on tooth #31, extensive decay, and a periapical abscess confirmed by radiograph. Tooth deemed non-restorable. Extraction is planned to address pain and infection."

Best Practices for Writing SOAP Notes

1. Be Detailed Yet Concise: Avoid vague descriptions; be specific about findings and recommendations.

2. Use Dental Terminology: Proper terminology ensures clarity and professionalism.

3. Ensure Legibility: Whether handwritten or digital, ensure notes are easy to read and understand.

4. Stay Objective: Focus on facts and avoid personal opinions.

5. Timeliness: Write notes immediately after the appointment to ensure accuracy.

Properly written SOAP notes not only enhance patient care but also support smooth claim submissions, ensuring your dental office’s financial health and compliance.

Published 12/12/2024