Stories. We all have them. But if we talk about the ending before showing the circumstances that occurred before it, our stories don’t make sense.
Chart notes for dentistry are the stories we tell about our patients. To tell these stories accurately, we must tell them well.
There is a structure in medical and dental notes that we’ve gotten away from (to a large degree through the habit of texting) and we need to get back to it. Before we talk about what a good chart note looks like, let’s review the “SOAP” structure:
S – Subjective:
This is the information provided by the patient, including symptoms, disability, function, lack of function and history. It needs to be very detailed and the information should come from the patient, caregiver or family member.
O – Objective:
This is a narration that is an objective observation of the patient and his or her problem. These observations are measurable diagnostics such as duration, frequency and equipment used. Included in the objective is range of motion, circulation, palpation (soft and hard tissue), manual muscular tests and special tests (HbA1c, PH, oral cancer screening with a tool, sleep screening).
A – Assessment:
This part of the SOAP structure is based on the doctor’s professional opinion. It includes the frequency and duration of treatment.
P – Plan:
Make sure to include short- and long-term plans. If there are recommendations for lifestyle changes, such as smoking cessation, make sure they are recorded. This section should also include the outcomes you expect, such as increased strength, pain reduction and range of motion.
Here are some other points that should be in the plan:
- Future treatment should be noted in all follow-up notes until completed.
- No vague descriptions should be included in the plan.
- Next visit and treatment plan for upcoming appointment should be recorded.
Here is a sample of a great SOAP note.
S: A 23-year-old male presents stating, “My lower left jaw in the back has been sore for the past few days.”
History of present illness: Pt says there has been swelling for the past three days, previously asymptomatic.
Medical history: medical conditions – Asthma; medications – Albuterol; allergies – seasonal pollen; past sx – gall bladder removal 2009; social history: tobacco and alcohol use daily.
O: Vitals: BP - 123/75 HR - 67 HbA1c - 5.0
Clinical exam: CBCT taken and reviewed today.
Extraoral – (Asymmetry, swelling, erythema, pain, paresthesia, infection, TMJ). No asymmetry or swelling. Pt points to 17 for pain extra orally.
Intraoral – (Swelling, exudate, erythema, hemorrhage, mobility, occlusion, pain, biotype, hard tissue, infection) 16 has supraerupted and occluding on pericoronal tissue of 17. 17 has partially erupted, has erythematous tissue, no hemorrhage, slight exudate, fetid odor, pain to palpation pericoronal tissue 17.
A: Asthmatic – exercise-induced, Smoker (1 pack per day) 16 supraerupted and occluding on opposing gingiva 17 pericoronitis.
P: Removed 16 today with operculectomy, consent signed.
Prescribed: Amoxicillin 500mg 1 BID x 10 days, Motrin 800mg Q 4-6 h x 4 days, Tylenol 3 Q 4-6 h x 4 days as needed for pain.
Healing evaluation scheduled for 10.25.19
Notice that the surgical part of this note is not included because it was a separate procedure.
Always remember that a great SOAP note comes from our doctors working collaboratively with the clinical and administrative team.
About the author
Laurie Owens is the owner and founder of Shifting the Focus, a dental consulting service aiming to allow patients to fully use their insurance benefits. She is also the director of medical billing education at Devdent. She is a Certified Professional Coder (CPC) and a Certified Professional Biller (CPB). Contact her at firstname.lastname@example.org or at 425-280-1542.