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SOAP for Medications

SOAP of a Medication

  • Every prescribed or over-the-counter medication and every herbal remedy or nuitriceutical must have a SOAP

  • The medication SOAP should be in the same text box with the condition for which it is being taken

 

  • Subjective:

    • Generic name of drug

    • Brand name of the drug - only if this is what the patient is taking

    • Pharmacological category - be specific - "Antihypertensive" is not adequate

    • Why the patient is taking this drug (do not list every indication for this drug)

    • The dosage the patient is taking

    • Local anesthetic vasoconstrictor precautions (if none, "No LA/VC")

    • Effects on dental treatment (if none, "No effects on dental treatment")

    • Effects on bleeding (if none, "No effects on bleeding")

    • Cardiovascular effect - ONLY list the following:

      • Hypertension

      • Hypotension

      • Orthostatic hypotension

      • Bradycardia

      • Tachycardia

      • Bradypnea

      • Tachypnea

    • Information from the patient related to side effects of the drug (bleeding, dry mouth, etc), or the negative.  Example:  Patient says that she has noticed that her mouth is dry  vs.  the patient denies having a dry mouth.

  • Objective:

    • Vital signs - Note the actual vital signs ONLY if they could be affected by the drug (see above)

    • Oral conditions - if they could be caused by the drug (dry mouth, ulcerations, conditions suggestive of candidiasis), or the negative.  Example:  The mouth appears dry; mouth mirror sticks to soft tissue and little pooling of saliva is seen in the floor of the mouth vs.  All tissues appear moist and there is normal pooling of saliva in the floor of the mouth.

  • Assessment:

    • This is the most IMPORTANT step

    • There must ALWAYS be an assessment

    • State how the medication is CURRENTLY affecting the patient, or the negative; for example "no current effects on salivary flow"

    • State if the patient is at risk for an effect in the future, for example "patient is at continued risk for gingival hyperplasia"

    • 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 of this medication

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

    • Examples:  

      • Take BP and pulse before each appointment (if these might be effected in the future)

      • Use additional local methods of hemostasis (if bleeding is a possiblity)

      • Continue to monitor for xerostomia

      • Implement caries risk reduction protocol (if patient is currently is suffering from xerostomia)

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