1. Omar Hamad AlKadhi, RCsDP
SOAP
Omar Hamad AlKadhi
1

2. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
Subjective
Objective
• Contents:
• Slide 3-4: Introduction • Slide #8: Assessment
Plan
• Slide#5: History • Slide #9: Plan
• Slide #6: Subjective • Slide #10-11: Example
• Slide #7: Objective
Assessment
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3. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
SOAP
• Importance of complete and efficient
noting.
• The SOAP system is designed to
organize and simplify noting in
hospital and office settings for all
healthcare professionals.
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4. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
Subjective
Objective
• Its a square!
Plan
• Put all the information inside.
Assessment
4

5. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
SOAP
• Start with a brief history.
• (Patient’s age, Nationality, Gender ,
Occupation, Past medical history,
Habits, and Past dental history).
5

6. S
Omar Hamad AlKadhi, RCsDP
Contents
Subjective
• Subjective, Symptoms, Chief
Complaint, History of present illness.
6

7. O
Omar Hamad AlKadhi, RCsDP
Contents
Objective
• What clinical and radiographic
examinations reveal.
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8. A
Omar Hamad AlKadhi, RCsDP
Contents
• Assessment, Problem list, Diagnosis.
The list is better be numbered and
corresponding numbers in the “Plan”
section are made.
Assessment
8

9. P
Omar Hamad AlKadhi, RCsDP
Contents
Plan
• Plan of the treatment, What is going to
be done today, and in the Next Visit.
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10. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
Useful Abbreviations Example
• Pt Patient
• YO Years Old
• Med. Medical
• Hx History
• NKDA No Known Drug Allergies • Hx:
• Cig. Cigarettes
• EOE Extra-Oral Examination • Pt is 22 yo Saudi , Student. Med Hx is
• IOE Intra-Oral Examination
• Tx Treatment not significant. NKDA. Not using any
• ē
With
drugs. Smoker 1/2 pack a day of cig.
• Tab. Tablet
• PRN As needed Dental Hx includes several restoration,
• Q6H Every 6 hours
•
Male
RCT and extraction.
•
Female
• S:
• CC: "I have severe pain in my upper left
last tooth (T#26), the pain is spontaneous
and it started 2 days ago, it is better
Subjective when I take Panadol, and I want to fix all
my teeth".
Objective
Assessment
Plan
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11. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
Useful Abbreviations Example
• Pt Patient
• YO Years Old
• Med. Medical
• Hx History
• O:
• NKDA No Known Drug Allergies • EOE:
• Cig. Cigarettes
• EOE Extra-Oral Examination • Lymph nodes, TMJ, Skin, Lips, and Face
• IOE Intra-Oral Examination all WNL.
• Tx Treatment
• ē
With • IOE:
• Tab. Tablet
• PRN As needed
• T#26 Thermal test revealed lingering
• Q6H Every 6 hours pain response (CO2).
•
Male
• T#26 is tender to palpation and
•
Female
percussion.
• Moderate plaque accumulation,
Generalized gingival inflammation,
BOP, Loss of stippling, Slight redness,
and Edema (see chart).
Subjective • RR of t# 46. Missing t#24.
• Slight drifting of t#23, 25 into space of
Objective missing t#24.
• Radiographically:
Assessment
•T#26, widening of the PDL space,
and a well defined, corticated
radiolucent lesion.
Plan
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12. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
Useful Abbreviations Example
• Pt Patient
• YO Years Old
• Med. Medical
• Hx History
• NKDA No Known Drug Allergies
• Cig. Cigarettes
• EOE Extra-Oral Examination
• IOE Intra-Oral Examination
• Tx Treatment
• ē
With
• Tab. Tablet
• PRN As needed
• A:
• Q6H Every 6 hours 1. T#26, Caries, Irreversible pulpitis, and
•
Male
Acute Apical Abscess.
•
Female
2. Generalized Moderate Plaque-induced
gingival disease.
3. RR of t#46.
4. Caries in t#16, 26, 34.
5. Missing t#24.
Subjective
Objective
Assessment
Plan
12

13. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
Useful Abbreviations Example
• Pt Patient
• YO Years Old
• Med. Medical
• Hx History
• NKDA No Known Drug Allergies
• Cig. Cigarettes
• EOE Extra-Oral Examination
• IOE Intra-Oral Examination
• Tx Treatment
• ē
With
• Tab. Tablet
• PRN As needed
• Q6H Every 6 hours • P:
•
Male
1. RCT and cusp coverage.
•
Female
2. Scaling and polishing.
3. Extraction of the RR of t#46.
4. Removal of caries and restoration of t#16,
34.
5. Implant or FPD in the space of missing
Subjective t#24.
Objective
Assessment
Plan
13

14. S O A P
Omar Hamad AlKadhi, RCsDP
Contents
Useful Abbreviations Procedure
• Pt Patient
• YO Years Old • Today:
• Med. Medical
• Hx History
• Explained the tx to the patient.
• NKDA No Known Drug Allergies • Infiltration anesthesia was administered, 2 carpules 2% lidocaine ē 1:100k adrenaline in the
• Cig. Cigarettes
• EOE Extra-Oral Examination
area of t#26.
• IOE Intra-Oral Examination • R.D. Was applied, single isolation.
• Tx Treatment
• ē
With • Caries was removed using a small diamond round bur.
• Tab. Tablet
• Access cavity was made.
• PRN As needed
• Q6H Every 6 hours • Canals were identified (P, DB, MB I, MB II).
•
Male
• Pulp extirpation was done using a barbed broach #15.
•
Female
• WL was determined using the apex locator and confirmed radiographically, (P: 20 mm, DB:
19 mm, MB I: 19 mm, and MB II: 18 mm).
• Instrumentation was made ē K-files #15, #20, and #25.
• Intra-canal medicament (CaOH) was applied.
• 2 cotton pellets were placed.
Subjective • The cavity was sealed using metal reinforced glass ionomer cement.
• Pt was instructed to:
Objective • Improve OH.
• Take Ibuprofen 400 mg tab. Q6H PRN x3 days.
Assessment • N.V.:
• instrumentation and obturation of the canals.
Plan
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15. Omar Hamad AlKadhi, RCsDP
Contents
Thank You
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