Created
Initial SOAP note created for patient James Thornton following comprehensive examination. Chief complaint, subjective findings, and objective clinical observations documented.
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ST
Sarah L. Thompson
Note IDSN-2026-0849
Note TypeConsultation
ProviderDr. Rivera
Last ModifiedToday, 9:52 AM
Completeness78% Complete
S
Subjective
Patient's chief complaint and reported symptoms
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Patient presents with chief complaint of tooth sensitivity in the upper right quadrant, specifically teeth #3 and #4. Reports sharp pain when consuming cold beverages (rated 7/10 on pain scale). Symptoms have been present for approximately 3 weeks. Patient denies trauma or recent dental procedures. Reports increased sensitivity when biting down on hard foods. Medical history: Hypertension (controlled with Lisinopril 10mg), No known drug allergies. Last dental visit: 8 months ago.
O
Objective
Clinical examination findings and diagnostic results
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Clinical examination findings:
- Periapical radiograph: Mild interproximal bone loss between teeth #3-#4
- Cold test: Positive and prolonged response on #3 (lingering 12 seconds post-stimulus)
- Percussion test: Mild sensitivity on #3
- Probing depths: 3-4mm generalized, no bleeding on probing
- Visual: Occlusal wear facets noted on #2, #3. No visible caries.
- Soft tissue: WNL — no swelling or erythema
- Occlusal assessment: Class I molar relationship bilaterally
A
Assessment
Clinical diagnosis and problem identification
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Primary Diagnosis:
1. Reversible pulpitis — Tooth #3 (D8680)
2. Bruxism / Para-functional habit — contributing etiology
Differential Diagnoses considered:
- Irreversible pulpitis (ruled out — pain does not linger >30 seconds)
- Cracked tooth syndrome (no definitive crack noted on transillumination)
- Dentinal hypersensitivity secondary to enamel wear
Prognosis: Favorable with appropriate intervention and occlusal guard therapy.
This section has been approved and is read-only. Contact the reviewing doctor to request amendments.
P
Plan
Treatment plan, medications, and follow-up schedule
667 chars
Treatment Plan:
1. Desensitizing agent application (Gluma) on exposed dentin — Tooth #3, today
2. Custom occlusal guard fabrication — upper arch; impression taken today
3. Fluoride varnish (5% NaF) application at today's appointment
4. Patient education: Bruxism awareness, nightguard importance, dietary modifications
Medications:
- Sensodyne Pronamel toothpaste (OTC) — twice daily
- Ibuprofen 400mg PRN for discomfort (no more than 3 days)
Follow-up:
- 2-week recall for occlusal guard delivery and adjustment
- 6-month recall for re-evaluation of sensitivity and guard wear compliance
Referral: Consult with periodontist if bone loss progresses at next recall.
SOAP Methodology Reference
Clinical documentation framework guide — click any card to expand definitions
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S
Subjective
Patient-reported symptoms, chief complaint, pain levels, and relevant medical/dental history as described in the patient's own words.
Clinical Definition
The Subjective section captures everything the patient communicates — onset, duration, character, and severity of symptoms. It includes past dental history, medical conditions, current medications, and social factors affecting oral health.
Patient reports sharp pain on upper-right molar when biting
Sensitivity to cold beverages for approximately 2 weeks
No known drug allergies; takes lisinopril 10mg daily
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O
Objective
Clinical findings from physical examination, diagnostic measurements, radiographic findings, and quantifiable test results observed by the clinician.
Clinical Definition
Objective data encompasses direct clinical observations: periodontal probing depths, radiographic bone levels, pulp vitality testing, intraoral photographs, CBCT findings, and any measurable signs present during the appointment.
Periapical radiograph shows periapical radiolucency on tooth #3
Probing depths 4-6mm across buccal surfaces of posterior quadrant
Positive response to cold test on #14; prolonged sensitivity noted
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A
Assessment
Clinical diagnosis, differential diagnoses, and professional impression based on synthesizing the subjective and objective findings.
Clinical Definition
The Assessment represents the clinician's professional judgment — the primary diagnosis (with applicable ICD-10 codes), differential diagnoses considered, prognosis for affected teeth, and the clinical reasoning connecting findings to conclusions.
Irreversible pulpitis, symptomatic — tooth #3 (K04.01)
Generalized moderate periodontitis, stage II grade B
Rule out cracked tooth syndrome on #14; monitor with bitewing series
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P
Plan
Recommended treatment protocols, procedures scheduled, prescriptions issued, patient education provided, and follow-up appointment criteria.
Clinical Definition
The Plan outlines all next steps: immediate procedures (extractions, RCT, scaling), prescriptions with dosing, specialist referrals, home care instructions, and the timeline for re-evaluation. It links directly to the Treatment Planning and Prescriptions modules.
Initiate root canal therapy on #3; refer to endodontics if needed
Full-mouth debridement + SRP quadrants 1 & 2 at next visit
Amoxicillin 500mg TID x 7 days; ibuprofen 600mg PRN for pain
Legend:
SubjectiveObjectiveAssessmentPlan
Approval Workflow
Assigned Reviewer
EV
Dr. Elena VasquezLead Orthodontist — DDS, MSDAssigned Approver
Change Log
SOAP note created and initial Subjective section drafted
Objective findings updated — added periodontal probing depths
Assessment section revised — differential diagnosis expanded
Note submitted for doctor approval
Approval Actions
Digital Approval Attestation
By approving this note, I attest that the clinical documentation is accurate, complete, and complies with HIPAA guidelines and clinic protocols.
Digital Signature
Audit Trail
Document History
Complete log of all actions, edits, and approvals for this SOAP note.
1Created
2Edited
1Approved
1Rejected
Edited
Updated Assessment and Plan sections with revised diagnosis and updated treatment recommendations after reviewing digital X-rays.
2 fields changed
Assessment:Gingivitis (K05.1)→Moderate Periodontitis (K05.3)
Plan:Scaling & Polishing→Full-mouth debridement + Antibiotic therapy
System
Note automatically routed to Dr. Kevin Osei (Senior Periodontist) for peer review and approval per clinic protocol for periodontitis cases.
Rejected
SOAP note returned to author. Diagnosis requires supporting periodontal charting data with BPE scores and bleeding on probing (BOP) percentages.
Reviewer Comment
Please include full periodontal chart with BPE scores for all sextants, BOP percentage, and pocket depth measurements before resubmission. Clinical findings must support the K05.3 diagnosis.Edited
Added complete periodontal chart to Objective section. Included BPE scores, BOP measurements at 6 sites per tooth, and full pocket depth readings.
2 fields changed
Resubmitted
SOAP note resubmitted for approval with all requested clinical data appended. Cover note added addressing reviewer feedback.
Approved
SOAP note reviewed and approved. Clinical documentation meets standards for moderate periodontitis diagnosis. Note finalized and locked for patient record.
Approval Note
Documentation is thorough and supports the diagnosis. Treatment plan aligns with current periodontal management guidelines. Approved for final record.
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