Dental Encounter Note (SOAP)

Date: [encounter date]

Patient: [name, DOB]

Provider: [dentist name; hygienist if applicable]

Visit Type: [exam / procedure / emergency / recall / follow-up]

Subjective

Chief Complaint: [Patient-stated concern in quotes when available; clinical translation] (For routine recall with no concerns, state "No specific concerns; here for [recall/prophy/etc.].")

HPI: [Onset, location by tooth number or quadrant, provoking/palliating factors, severity, prior care, red flags when relevant] (Include only if a symptom or problem is being addressed; omit entirely for asymptomatic routine visits.)

History Update: ["Medical/dental history reviewed and updated; no changes" or describe relevant changes]

Medications: [Current medications or "No medications"]

Allergies: [Allergens with reaction type or "NKDA"]

Objective

Vitals: [Relevant vitals and pain score] (Include only when clinically indicated—sedation, medical risk, infection, significant pain; otherwise omit.)

Extraoral Exam: [Pertinent findings or "Within normal limits"]

Intraoral Exam: [Soft tissue findings; hard tissue findings by tooth number and surface using Universal notation; periodontal summary if assessed] (For limited visits, state "Comprehensive exam not performed" and document only relevant findings.)

Imaging: [Type obtained/reviewed; indication; interpretation with positive findings and meaningful negatives] (Omit if no imaging involved.)

Diagnostics: [Test type and results by tooth number] (Include only if pulp testing, transillumination, or other diagnostics performed.)

Assessment

(List diagnoses ordered by urgency then clinical priority. Include diagnosis, tooth number(s) and surfaces, with brief supporting evidence. Include differential only when diagnosis is uncertain.)

• [Diagnosis with tooth number(s) and surfaces] ([Supporting evidence])
• [Additional diagnosis as needed]

Plan

Consent: [Informed consent obtained after discussion of risks, benefits, and alternatives] (For refusal, document recommendation, refusal with patient-stated reasons, and that consequences were explained.)

Treatment Performed: [Procedure with tooth number(s) and surfaces; anesthesia type/volume/site if used; key materials/technique; outcome and tolerance] (Group related procedures logically. Omit if no procedures performed.)

Prescriptions: [Medication, dose, quantity, directions, indication] (State "No prescriptions" if none.)

Referrals: [Specialist type, reason, urgency] (Omit if none.)

Follow-up: [Next visit type, timing, planned procedures by tooth; contingency instructions if symptoms worsen]

Post-op Instructions: [Written/verbal instructions provided; key precautions] (Omit for visits without procedures.)

(Use Universal Tooth Designation System: #1–32 for permanent, A–T for primary. For missing information, use "Not assessed", "Unknown", "Denied", or "N/A" rather than leaving blank. Do not include financial information. Document refusals factually.)