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SUBJECTIVE

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Subjective the purpose of the patients dental visit

description of symptoms in the patients OWNwords:

Onset Chronology

Quality SeverityModifying Factors Additional Symptoms

Treatment

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Example:

Patient presents complaining of missing tooth #7. States

that the tooth was extracted after an unsuccessful attempt

at restoration. Past medical history is non-contributory,

however patient admits to smoking 1/2 pack per day of

cigarettes. Past dental history: Patient receives dental

cleanings irregularly, does not use floss.

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OBJECTIVE

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Objective Clinicians Examination

Documents objective, repeatable, and traceable facts

about the patients statusVital signs

Findings from physical examinations

Results from laboratory Measurements

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Example:

Intra-oral exam reveals tongue, palate, FOM WNL. Gingiva ispink and stippled with localized swelling and redness in

lower anterior and maxilla posterior regions. Pocketing anddentition as charted (see charting). Missing tooth #7.

Adjacent teeth #6, 8 show slight drifting into space of #7.Slight plaque, moderate stain. Slight stick to explorer inocclusal pits maxillary premolars, however bite-wingradiographs reveal no sign of decay. #31 with large IRM.Radiographic exam reveals IRM #31 is close to pulp. Bone lossseen in area of #23-26.

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ASSESMENT

the diagnosis of the patients condition done by the

dentist

diagnosis may be clear or there may be severaldiagnostic possibilities.

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Example:

1) Missing #72) Localized periodontal disease #23-263) #31 restoration close to pulp, poss. pulpal pathology4) Max. premolars non-carious

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Planning

proposedtreatment

Plan may include:ordering labs

referrals

procedures performed

medications prescribed

patient follow-up care instructions etc.

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Example:Today: Examination, full mouth series radiographs taken andread. Alg. imps for study

1) Explained to patient that there are several different ways torestore missing #7. Will review study casts and discuss optionsand fees at next appointment.

2)Expl'd to patient need for more frequent prophys, and the useof floss.

3)Will evaluate pulpal status of #31 with endodontic consult

4)Recommend no treatment for occlusal fissures of premolarsRTC (Return to clinic) Discuss treatment plan options.

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SOAPformat the usage of abbreviations is standard

individual making the notation sign their name and listtheir credentials

If an error is made, a single line should be drawn throughthe error, dated and initialed, and the correction written.

be written fluently and without blank lines between theentries