SOAP for Medical Conditions or Symptoms

Every "YES" answer must have a SOAP!

Subjective:

• Anything the patient tells you about the condition, any answers the patient gives you to the questions about the condition.

• Lab tests the patient may give you, verbally or in a report.

• Any information that is NOT colected during your EXAMINATION of the patient

Objective:

• Vital signs - but ONLY if they provide information about the specific disease

• Extraoral clinical signs that could be related to the medical problem

  • Examples:  tremor, labored breathing, walking slowly, poor cognitive function

• Intraoral manifestations of the medical condition that are present

• Many conditions will have NO objective findings, therefore "None" is appropriate 

Assessment:

• This is the most IMPORTANT step

• There must ALWAYS be an assessment

• Answer these questions:

  • From the information you have collected, what is the status of this disease (controlled, poorly controlled, not controlled)

  • What is the magnitude of the risk for the patient and dental treatment due to this disease?

• If it is determined that the condition will not effect dental treatment, write "No effect on dental treatment" or "NEDT".  

Plan

• This should include the treatment modifications needed to lessen health related risks

• If the Assessment = NEDT, or no risk, then the plan can be NONE.

• Examples:  

  • Follow closely to monitor healing and assess for infection

  • Take BP and pulse before each appointment

  • Stress reduction protocols

  • Use additional local methods of hemostasis

  • Request medical consultation