soap noting system

Omar Hamad AlKadhi, RCsDP

SOAPOmar Hamad AlKadhi

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• Contents:

• Slide 3-4: Introduction

• Slide#5: History

• Slide #6: Subjective

• Slide #7: Objective

• Slide #8: Assessment

• Slide #9: Plan

• Slide #10-11: Example

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Contents PSubjective

Objective

Assessment

Plan

O AS P


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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S O A PContents


• Its a square!

• Put all the information inside.

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S O A PSubjective

Objective

Assessment

Plan

Contents


• Start with a brief history.

• (Patient’s age, Nationality, Gender , Occupation, Past medical history, Habits, and Past dental history).

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S O A PSOAP

Contents


Subjective

• Subjective, Symptoms, Chief Complaint, History of present illness.

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Contents S


• What clinical and radiographic examinations reveal.

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Objective

Contents O


Assessment

• Assessment, Problem list, Diagnosis. The list is better be numbered and corresponding numbers in the “Plan” section are made.

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Contents A


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Plan • Plan of the treatment, What is going to

be done today, and in the Next Visit.

Contents P


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Useful Abbreviations

• 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• ♂ Male

• ♀ Female

• Hx:• Pt is 22 yo Saudi ♂, Student. Med Hx is

not significant. NKDA. Not using any drugs. Smoker 1/2 pack a day of cig. Dental Hx includes several restoration, RCT and extraction.

• 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 when I take Panadol, and I want to fix all my teeth".

SubjectiveObjectiveAssessmentPlan

S O A PExample

Contents


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• ♀ Female

• O:• EOE:

• Lymph nodes, TMJ, Skin, Lips, and Face all WNL.

• IOE:• T#26 Thermal test revealed lingering

pain response (CO2).• T#26 is tender to palpation and

percussion.• Moderate plaque accumulat ion,

Generalized gingival inflammation, BOP, Loss of stippling, Slight redness, and Edema (see chart).

• RR of t# 46. Missing t#24. • Slight drifting of t#23, 25 into space of

missing t#24.• Radiographically:

•T#26, widening of the PDL space, and a well defined, corticated radiolucent lesion.


S O A PExample

Contents


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• ♀ Female

• A: 1.T#26, Caries, Irreversible pulpitis, and

Acute Apical Abscess.2.Generalized Moderate Plaque-induced

gingival disease.3.RR of t#46.4.Caries in t#16, 26, 34.5.Missing t#24.


S O A PExample

Contents


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• ♀ Female

• P:1.RCT and cusp coverage.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

t#24.SubjectiveObjectiveAssessmentPlan

S O A PExample

Contents


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• Today:• Explained the tx to the patient.• Infiltration anesthesia was administered, 2 carpules 2% lidocaine ē 1:100k adrenaline in the

area of t#26.• R.D. Was applied, single isolation. • Caries was removed using a small diamond round bur. • Access cavity was made. • Canals were identified (P, DB, MB I, MB II).• Pulp extirpation was done using a barbed broach #15.• 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. • The cavity was sealed using metal reinforced glass ionomer cement.• Pt was instructed to:• Improve OH.• Take Ibuprofen 400 mg tab. Q6H PRN x3 days.

• N.V.:• instrumentation and obturation of the canals.

S O A PProcedure

Contents



• ♀ Female



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Thank You

Contents

soap noting system

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