Dental SOAP Notes Template and Examples

Updated: November 20, 2023

Dental professionals often need a systematic record of patient information and treatment details. An effective documentation process is crucial for maintaining accurate patient records, ensuring continuity of care, and meeting legal requirements.

Type less. Say more.

Leave boring, repetitive copying & pasting in the past. Share text and images wherever you can type--so you can focus on what matters most.

(No credit card required)

What Are Dental SOAP Notes?

SOAP notes are a standardized method for recording patient information and are commonly used in the dental field. They help organize data in a clear, concise, and systematic way.

What Does SOAP Stand For?

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. Each component plays a crucial role in patient documentation:

  • Subjective: The patient’s reported symptoms and concerns.
  • Objective: The clinician’s observations, including examination findings and test results.
  • Assessment: The dentist’s diagnosis based on the subjective and objective information.
  • Plan: The proposed treatment plan, including any procedures, medications, or follow-up visits.

When Are SOAP Notes Used in Dentistry?

SOAP notes are utilized at every patient visit to document the encounter and are especially important for follow-up visits to track the patient’s progress and response to treatment.

Why Are Dental SOAP Note Templates Useful for Dentists?

Templates can streamline the documentation process, ensure consistency across patient records, and save time. They also serve as a checklist to ensure that all important aspects of the patient’s visit are recorded.

Dental SOAP Notes Template

A typical Dental SOAP Note Template would include sections for each component of the SOAP:

SOAP Notes Template Copy Snippet Copied!

Subjective:
– Patient Name:
– Age:
– Gender:
– Date of Visit:
– Chief Complaint:
– History of Present Illness:
– Medical History:
– Dental History:
– Review of Systems (if relevant):
– Medications:
– Allergies:

Objective:
– Clinical Findings:
– Radiographic Findings:
– Periodontal Status:
– Dental Charting:
– Vital Signs:

Assessment:
– Diagnosis:
– Differential Diagnosis (if relevant):

Plan:
– Treatment Plan:
– Medications Prescribed:
– Referrals:
– Patient Education:
– Follow-Up:

Dental SOAP Notes Examples

Dental SOAP notes might look something like this:

Example 1

Subjective:

  • Patient Name: John Doe
  • Age: 32
  • Gender: Male
  • Date of Visit: 2023-11-13
  • Chief Complaint: Toothache in the lower right quadrant
  • History of Present Illness: Pain for 2 days, aggravated by cold drinks
  • Medical History: Healthy
  • Dental History: Last check-up 1 year ago
  • Medications: None
  • Allergies: None

Objective:

  • Clinical Findings: Caries on lower right first molar
  • Radiographic Findings: Deep decay close to the pulp
  • Periodontal Status: Healthy
  • Dental Charting: 46 carious
  • Vital Signs: BP 120/80, HR 72

Assessment:

  • Diagnosis: Dental Caries with possible pulp involvement
  • Differential Diagnosis: Reversible pulpitis

Plan:

  • Treatment Plan: Root canal treatment on 46
  • Medications Prescribed: Ibuprofen 400mg for pain
  • Referrals: None
  • Patient Education: Importance of regular dental check-ups
  • Follow-Up: Appointment for root canal treatment in 1 week
Example 2

Subjective:

  • Patient Name: Jane Smith
  • Age: 45
  • Gender: Female
  • Date of Visit: 2023-11-13
  • Chief Complaint: Bleeding gums while brushing
  • Medical History: Diabetic
  • Dental History: Regular check-ups
  • Medications: Metformin
  • Allergies: Penicillin

Objective:

  • Clinical Findings: Gingival inflammation, plaque accumulation
  • Radiographic Findings: Bone loss in posterior regions
  • Periodontal Status: Periodontitis
  • Dental Charting: Generalized bleeding on probing
  • Vital Signs: BP 130/85, HR 78

Assessment:

  • Diagnosis: Chronic Periodontitis
  • Differential Diagnosis: Gingivitis

Plan:

  • Treatment Plan: Scaling and root planing, oral hygiene instruction
  • Medications Prescribed: Chlorhexidine mouthwash
  • Referrals: None
  • Patient Education: Diabetes and periodontal health
  • Follow-Up: Reevaluation in 4 weeks
Example 3

Subjective:

  • Patient Name: Emily Nguyen
  • Age: 28
  • Gender: Female
  • Date of Visit: 2023-11-13
  • Chief Complaint: Desire to improve smile aesthetics
  • Medical History: No significant findings
  • Dental History: Orthodontic treatment as a teenager
  • Medications: None
  • Allergies: None

Objective:

  • Clinical Findings: Mild crowding of anterior teeth, good oral hygiene
  • Radiographic Findings: No abnormalities
  • Periodontal Status: Healthy
  • Dental Charting: No caries
  • Vital Signs: BP 115/75, HR 70

Assessment:

  • Diagnosis: Cosmetic concern
  • Differential Diagnosis: N/A

Plan:

  • Treatment Plan: Veneers for anterior teeth
  • Medications Prescribed: None
  • Referrals: Cosmetic consultation
  • Patient Education: Veneer care and maintenance
  • Follow-Up: Next appointment for veneer preparation

Notes help facilitate the organization of patient information, support decision-making, and enhance communication among dental care providers. By implementing a template for SOAP notes in your dental practice, you can provide more consistent, quality care to your patients.

What is TextExpander

With TextExpander, you can store and quickly expand full email templates, Slack messages, and more anywhere you type. That means no more misspellings, no need to memorize complex instructions, or type the same things over and over again. See for yourself here:

Not able to play the video? Click here to watch the video

Try it for yourself

With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.

Subjective: <br>- Patient Name: <br>- Age: <br>- Gender: <br>- Date of Visit: <br>- Chief Complaint: <br>- History of Present Illness: <br>- Medical History: <br>- Dental History: <br>- Review of Systems (if relevant): <br>- Medications: <br>- Allergies: <br> <br>Objective: <br>- Clinical Findings: <br>- Radiographic Findings: <br>- Periodontal Status: <br>- Dental Charting: <br>- Vital Signs: <br> <br>Assessment: <br>- Diagnosis: <br>- Differential Diagnosis (if relevant): <br> <br>Plan: <br>- Treatment Plan: <br>- Medications Prescribed: <br>- Referrals: <br>- Patient Education: <br>- Follow-Up:
Subjective: <br>- Patient Name: John Doe <br>- Age: 32 <br>- Gender: Male <br>- Date of Visit: 2023-11-13 <br>- Chief Complaint: Toothache in the lower right quadrant <br>- History of Present Illness: Pain for 2 days, aggravated by cold drinks <br>- Medical History: Healthy <br>- Dental History: Last check-up 1 year ago <br>- Medications: None <br>- Allergies: None <br> <br>Objective: <br>- Clinical Findings: Caries on lower right first molar <br>- Radiographic Findings: Deep decay close to the pulp <br>- Periodontal Status: Healthy <br>- Dental Charting: 46 carious <br>- Vital Signs: BP 120/80, HR 72 <br> <br>Assessment: <br>- Diagnosis: Dental Caries with possible pulp involvement <br>- Differential Diagnosis: Reversible pulpitis <br> <br>Plan: <br>- Treatment Plan: Root canal treatment on 46 <br>- Medications Prescribed: Ibuprofen 400mg for pain <br>- Referrals: None <br>- Patient Education: Importance of regular dental check-ups <br>- Follow-Up: Appointment for root canal treatment in 1 week
Subjective: <br>- Patient Name: Jane Smith <br>- Age: 45 <br>- Gender: Female <br>- Date of Visit: 2023-11-13 <br>- Chief Complaint: Bleeding gums while brushing <br>- Medical History: Diabetic <br>- Dental History: Regular check-ups <br>- Medications: Metformin <br>- Allergies: Penicillin <br> <br>Objective: <br>- Clinical Findings: Gingival inflammation, plaque accumulation <br>- Radiographic Findings: Bone loss in posterior regions <br>- Periodontal Status: Periodontitis <br>- Dental Charting: Generalized bleeding on probing <br>- Vital Signs: BP 130/85, HR 78 <br> <br>Assessment: <br>- Diagnosis: Chronic Periodontitis <br>- Differential Diagnosis: Gingivitis <br> <br>Plan: <br>- Treatment Plan: Scaling and root planing, oral hygiene instruction <br>- Medications Prescribed: Chlorhexidine mouthwash <br>- Referrals: None <br>- Patient Education: Diabetes and periodontal health <br>- Follow-Up: Reevaluation in 4 weeks
Subjective: <br>- Patient Name: Emily Nguyen <br>- Age: 28 <br>- Gender: Female <br>- Date of Visit: 2023-11-13 <br>- Chief Complaint: Desire to improve smile aesthetics <br>- Medical History: No significant findings <br>- Dental History: Orthodontic treatment as a teenager <br>- Medications: None <br>- Allergies: None <br> <br>Objective: <br>- Clinical Findings: Mild crowding of anterior teeth, good oral hygiene <br>- Radiographic Findings: No abnormalities <br>- Periodontal Status: Healthy <br>- Dental Charting: No caries <br>- Vital Signs: BP 115/75, HR 70 <br> <br>Assessment: <br>- Diagnosis: Cosmetic concern <br>- Differential Diagnosis: N/A <br> <br>Plan: <br>- Treatment Plan: Veneers for anterior teeth <br>- Medications Prescribed: None <br>- Referrals: Cosmetic consultation <br>- Patient Education: Veneer care and maintenance <br>- Follow-Up: Next appointment for veneer preparation

Work smarter.

With TextExpander, you can store and quickly expand snippets anywhere you type. That means you'll never have to misspell, memorize, or type the same things over and over, ever again.

|

Less Repetition, More Customer Delight

TextExpander gives your team the power to do what they do best — faster.