Oral and Maxillofacial Surgery Clinic Note (SOAP)

Date: [Date]

Patient Name: [Full name]

Provider: [Provider name and credentials]

Encounter Type: [new consult / follow-up / post-op]

Referring Provider: [Referring provider name] (Include only if applicable.)

Subjective

Chief Complaint: [Primary concern in patient's words]

HPI: [Narrative description of presenting symptoms, onset, duration, course, severity, and functional impact on chewing, speaking, and sleep. For follow-ups, document interval change: better/worse/same.] (Include relevant red flags based on problem type: infection—fever, dysphagia, trismus progression, airway symptoms; nerve concerns—paresthesia distribution and onset; TMJ—joint noises, locking, deviation, parafunction.)

Relevant History:

• [Pertinent medical conditions affecting anesthesia/surgery: cardiac, pulmonary, bleeding disorders, OSA]
• [Current medications, especially anticoagulants/antiplatelets, bisphosphonates/denosumab, recent antibiotics]
• [Allergies with reaction type] (If unknown, document: "Allergy status not confirmed.")
• [Relevant dental/OMS history: prior extractions, implants, TMJ treatments, complications]
• [Tobacco/substance use if relevant to surgical planning or sedation]
• [Pregnancy status when sedation planned] (If unknown and relevant, document: "Pregnancy status not confirmed.")

Objective

Vitals: [Relevant vitals as obtained] (If deferred, state reason.)

Exam: (Document only systems assessed; do not auto-populate normal findings.)

• Extraoral: [Facial symmetry, swelling, lymphadenopathy, TMJ palpation, cranial nerve V/VII when indicated]
• Intraoral: [Mucosa/gingiva, vestibule/floor of mouth, tooth-specific findings using Universal numbering (#1–#32), pericoronitis, drainage/fluctuance]
• Occlusion: [Angle class, overjet/overbite, crossbite, midline discrepancies as relevant]
• Jaw Function: [Maximum incisal opening in mm, note if pain-limited; deviation; joint noises; locking]

Imaging: [Modality, date, source (in-house vs outside), and key findings relevant to clinical question] (Third molars: impaction type, IAN proximity, root morphology. Implants: bone dimensions, proximity to vital structures, grafting needs. Infection: source tooth, space involvement. If imaging unavailable, state what is missing and how it limits decision-making.)

Assessment

(Number problems in descending urgency. Include laterality and tooth number(s). State status: new/established, improving/stable/worsening. Include differential only when uncertainty affects management.)

1. [Problem 1]: [Working diagnosis with laterality and tooth number(s)] — [new / established], [improving / stable / worsening]. [Brief rationale linking key findings. Differential if relevant to management.]
2. [Additional problems as needed in same format]

Plan

(Organize by problem number from Assessment.)

1. [Problem 1] Plan: [Diagnostics with rationale; therapeutic plan including procedure(s) by tooth number and medications with dose/route/duration/indication; counseling/consent noting options discussed, patient decision, and material risks reviewed (e.g., nerve injury, sinus communication, infection, bleeding); follow-up timing; return precautions especially airway warning signs for infection cases.] (For opioid prescriptions, include rationale and quantity.)
2. [Repeat for each additional problem]

Prescriptions

(Include only if medications prescribed.)

• [Medication: dose/route/frequency/duration; indication] (For opioids, include rationale and quantity.)

[Nonpharmacologic measures: ice, elevation, soft diet, saltwater rinses as applicable]

Procedure Performed Today

(Include only if a procedure was performed at this visit.)

• Procedure/Site: [Procedure name, tooth number(s)/location]
• Anesthesia: [Type and agents used]
• Findings/Complications: [Intraoperative findings; complications or "none"]
• Specimens: [Specimen(s) sent to pathology, if any]

Care Coordination

(Include only if applicable.)

[Communication to referring provider; critical results communicated directly with recipient, method, and time]

(Safety-critical elements: If allergies, anticoagulant status, or pregnancy status when sedation planned are unknown, explicitly document "not confirmed" rather than omitting. Omit optional sections entirely if not applicable.)