Endodontics SOAP Note

Date: [Date]

Provider: [Provider name and credentials]

Encounter Type: [Consult / Follow-up / Emergency / Post-op]

Referring Provider: [Referring provider and reason for referral] (Include only if applicable.)

Tooth/Teeth of Concern: [Tooth number(s) with brief context]

Control Teeth Tested: [Contralateral/adjacent controls]

Subjective

Chief Complaint: [Patient's primary concern] (Use patient's own words when available. If asymptomatic, state reason for evaluation.)

History of Present Illness: [Onset, duration, pain character/severity, triggers/relievers, swelling/drainage, relevant prior dental events on involved tooth] (For follow-up visits, focus on interval changes.)

Relevant History: [Pertinent medical conditions, medications affecting treatment, allergies with reaction type, dental history of involved tooth]

Objective

Clinical Exam: [Extraoral findings; intraoral soft tissue findings including sinus tract presence; periodontal status around involved tooth]

Diagnostic Tests: [Summary of findings for involved tooth and controls: percussion, palpation, thermal response, EPT, bite test, mobility, probing as indicated] (Note any tests not performed and rationale.)

Imaging: [Type obtained/reviewed with dates; key findings including periapical status, canal morphology, prior treatment quality, resorption, fracture suspicion] (For CBCT, include clinical justification. If no imaging, state reason.)

Assessment

(Document per tooth addressed using standardized AAE terminology.)

Tooth #[number]:

Pulpal Diagnosis: [AAE pulpal diagnosis]

Periapical Diagnosis: [AAE periapical diagnosis]

Additional Findings: [Cracked tooth, resorption, perio-endo involvement] (Include only if applicable.)

Differential Diagnosis: [Differential considerations] (Include when tests conflict, symptoms not reproducible, or non-odontogenic etiology suspected.)

Prognosis/Complexity: [Prognosis and case difficulty] (Include if relevant to planning or referral.)

Plan

Treatment Recommendation: [Recommended treatment per tooth with rationale; alternatives discussed including no treatment; urgency]

Informed Consent: [Consent status] (Document that diagnosis, procedure, risks, benefits, prognosis, and alternatives were discussed; questions addressed; consent obtained. If refused or not obtained, document reason. Do not infer consent.)

Procedure Performed: [Anesthesia details; rubber dam isolation status; access and canal findings; working length determination; instrumentation/irrigation summary; medicament or obturation; post-op imaging; complications] (If no treatment rendered, state "No operative procedure performed." Rubber dam is required for nonsurgical endodontic treatment—if not achieved, document why and that definitive treatment was deferred.)

Medications: [Drug, dose, duration, indication if prescribed] (For antibiotics, document clinical justification or state why not indicated.)

Restoration: [Restorability assessment and recommended definitive restoration with timing]

Follow-up: [Next appointment type/timing; symptoms requiring urgent return; recall imaging interval; coordination with referring dentist if applicable]