How to Create SOAP Notes from the Patient’s Clinical Chart

More and more dental and medical insurance payers are demanding excellent clinical documentation in the form of SOAP format to back up procedures performed on patients that are members of their plans.  Whether covered by insurance or not, good clinical notes support the rationale for treatment and are necessary should there be a lawsuit or medical issue that requires the patient record be examined.

The following is an explanation in lay terms as to what is necessary to create SOAP documentation:

Subjective:  What is the patient’s chief complaint? What does the patient describe as symptoms?  What are the patients’ health issues that may affect the outcome of treatment as documented on the health history?

“(Name) presented with an emergency tooth pain. Patient pointed to the upper right area at #3.  Patient has history of heart valve replacement.”

Objective:  What do the doctor and clinical team see when examining the patient?  Monitor of vitals, mental state, history of illness and health issues related to diabetes, heart, implants, weight, smoking, pregnancy etc.?  What is the evidence of symptoms affecting the teeth, tissue and bone such as evidence of periodontal disease, endodontic infection, and fracture, decay, missing teeth and broken restorations and prosthetics?

“After evaluation of the upper right area, (dentist) recommended that a single periapical x-ray of #3 area be taken.  Patient sensitive to touch on #3 tooth.”

Assessment:  What does the doctor see as necessary for the needs of the patient to return them to health from information gathered in the subjective and objective discovery?  Write them down in a cohesive fashion of priority.

“Doctor recommended that the patient be referred to an endodontist for further evaluation of #3 and determine need for root canal therapy.”

Plan:  Establish a written treatment plan of action for the patient including number of appointments, codes and procedures and phases of treatments and any referrals to other specialists or providers.  “Patient instructed to make an appointment for full comprehensive evaluation and restorative treatment of #3.”