Omar Hamad AlKadhi, RCsDP
• Contents:
• Slide 3-4: Introduction
• Slide#5: History
• Slide #6: Subjective
• Slide #7: Objective
• Slide #8: Assessment
• Slide #9: Plan
• Slide #10-11: Example
2
Contents PSubjective
Objective
Assessment
Plan
O AS P
Omar Hamad AlKadhi, RCsDP
SOAP• Importance of complete and efficient
noting.
• The SOAP system is designed to organize and simplify noting in hospital and office settings for all healthcare professionals.
3
S O A PContents
Omar Hamad AlKadhi, RCsDP
• Its a square!
• Put all the information inside.
4
S O A PSubjective
Objective
Assessment
Plan
Contents
Omar Hamad AlKadhi, RCsDP
• Start with a brief history.
• (Patient’s age, Nationality, Gender , Occupation, Past medical history, Habits, and Past dental history).
5
S O A PSOAP
Contents
Omar Hamad AlKadhi, RCsDP
Subjective
• Subjective, Symptoms, Chief Complaint, History of present illness.
6
Contents S
Omar Hamad AlKadhi, RCsDP
• What clinical and radiographic examinations reveal.
7
Objective
Contents O
Omar Hamad AlKadhi, RCsDP
Assessment
• Assessment, Problem list, Diagnosis. The list is better be numbered and corresponding numbers in the “Plan” section are made.
8
Contents A
Omar Hamad AlKadhi, RCsDP
9
Plan • Plan of the treatment, What is going to
be done today, and in the Next Visit.
Contents P
Omar Hamad AlKadhi, RCsDP
10
Useful Abbreviations
• Pt Patient• YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed• Q6H Every 6 hours• ♂ Male
• ♀ Female
• Hx:• Pt is 22 yo Saudi ♂, Student. Med Hx is
not significant. NKDA. Not using any drugs. Smoker 1/2 pack a day of cig. Dental Hx includes several restoration, RCT and extraction.
• S:• CC: "I have severe pain in my upper left
last tooth (T#26), the pain is spontaneous and it started 2 days ago, it is better when I take Panadol, and I want to fix all my teeth".
SubjectiveObjectiveAssessmentPlan
S O A PExample
Contents
Omar Hamad AlKadhi, RCsDP
11
Useful Abbreviations
• Pt Patient• YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed• Q6H Every 6 hours• ♂ Male
• ♀ Female
• O:• EOE:
• Lymph nodes, TMJ, Skin, Lips, and Face all WNL.
• IOE:• T#26 Thermal test revealed lingering
pain response (CO2).• T#26 is tender to palpation and
percussion.• Moderate plaque accumulat ion,
Generalized gingival inflammation, BOP, Loss of stippling, Slight redness, and Edema (see chart).
• RR of t# 46. Missing t#24. • Slight drifting of t#23, 25 into space of
missing t#24.• Radiographically:
•T#26, widening of the PDL space, and a well defined, corticated radiolucent lesion.
SubjectiveObjectiveAssessmentPlan
S O A PExample
Contents
Omar Hamad AlKadhi, RCsDP
12
Useful Abbreviations
• Pt Patient• YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed• Q6H Every 6 hours• ♂ Male
• ♀ Female
• A: 1.T#26, Caries, Irreversible pulpitis, and
Acute Apical Abscess.2.Generalized Moderate Plaque-induced
gingival disease.3.RR of t#46.4.Caries in t#16, 26, 34.5.Missing t#24.
SubjectiveObjectiveAssessmentPlan
S O A PExample
Contents
Omar Hamad AlKadhi, RCsDP
13
Useful Abbreviations
• Pt Patient• YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed• Q6H Every 6 hours• ♂ Male
• ♀ Female
• P:1.RCT and cusp coverage.2.Scaling and polishing.3.Extraction of the RR of t#46.4.Removal of caries and restoration of t#16,
34.5. Implant or FPD in the space of missing
t#24.SubjectiveObjectiveAssessmentPlan
S O A PExample
Contents
Omar Hamad AlKadhi, RCsDP
14
• Today:• Explained the tx to the patient.• Infiltration anesthesia was administered, 2 carpules 2% lidocaine ē 1:100k adrenaline in the
area of t#26.• R.D. Was applied, single isolation. • Caries was removed using a small diamond round bur. • Access cavity was made. • Canals were identified (P, DB, MB I, MB II).• Pulp extirpation was done using a barbed broach #15.• WL was determined using the apex locator and confirmed radiographically, (P: 20 mm, DB:
19 mm, MB I: 19 mm, and MB II: 18 mm).• Instrumentation was made ē K-files #15, #20, and #25.• Intra-canal medicament (CaOH) was applied.• 2 cotton pellets were placed. • The cavity was sealed using metal reinforced glass ionomer cement.• Pt was instructed to:• Improve OH.• Take Ibuprofen 400 mg tab. Q6H PRN x3 days.
• N.V.:• instrumentation and obturation of the canals.
S O A PProcedure
Contents
Useful Abbreviations
• Pt Patient• YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed• Q6H Every 6 hours• ♂ Male
• ♀ Female
SubjectiveObjectiveAssessmentPlan