Years ago, when I was a new hygienist, it was not uncommon for me to write up very brief notes. In fact, because we used paper charts, I was told that I could only use one to two lines to document my work.
My usual entry looked like this: pro, fltx, 4 BWs, ex. My soft tissue note read something like: Med HX, OCE-neg, and gingivitis. Abbreviations were common and occupied less space on the written document.
Moving forward some 30 years, I now regularly use a SOAP note format. SOAP notes have been used in medicine for years; while there are numerous templates, the one I've shared below is what I find most useful in helping document findings. I have edited it to be more useful to practicing dental hygienists.
What is S-O-A-P about?
“S” stands for subjective. This is the information the patient provides to you. Examples are why they are there (not a good idea to complete a prophy when they thought they were there for a restoration), medical history information, medications and dosages, allergies, dental history, social history, consent, and vitals (this could possibly go under “O” but we always ask if they know what their numbers typically run, especially if they’re out of range).
Note: We do not recommend asking the question, “Any changes to your health or medications?” This is too broad, and many patients don’t realize the importance of or remember since their last visit. A better choice of words might be, “Since you were here in January of 2022, have you visited your doctor and what for? I am about to review the medications we have on file so please let me know if you have any changes to add or delete, or a dosage change.
“O” is the objective data that you gathered. This would include the EO/IO (extraoral/intraoral) findings, periodontal probing along with furcations, mobility, recession, CAL (clinical attachment loss), and BOP (bleeding on probing). You may already have your own list of what you cover in your EO/IO exam or you can find any number of lists online.
“A” is the assessment. This is limited to the periodontal hygiene diagnosis after you gather your information and apply it based on the 2017 Classification of Periodontal and Peri-implant Diseases updates. You should also add a prognosis based on the McGuire prognosis classification system.
“P” is the plans and procedures discussed or completed that day. It can be in paragraph form or bullets. Some prefer the paragraph format as it flows well. It might look like this:
PLAN/PROCEDURE: Completed Comprehensive Exam (or whatever procedure was completed that day). Reviewed and updated medical/dental/social hx. Vitals taken. Performed EO/IO exam, periodontal assessments, and completed all periodontal charting to include probing, BOP, recession, furcations, and mobility. Discussed findings with patient and answered all questions, (add any additional notes that are necessary here). Patient left clinic in good condition.
(Based on the common template used at Arizona School of Dentistry and Oral Health)
In our setting, we have numerous templates to choose from. We have a basic Comprehensive Exam form that you can see below, and then we add additional templates as needed such as the EO/IO exam, staging and grading guidelines, etc. You can revise your templates to suit your individual practice, but the goal is that each practitioner utilizes the same format to decrease the possibility of missing critical data. It also helps for uniformity when trying to locate certain key pieces of data such as “did we ever follow up on the lesion we noted on the EO/IO last month”?
As patients become savvy, and in some cases, more litigious, SOAP note documentation provides protection from legal actions.
Common reasons for dental malpractice cases
There are many reasons a dental patient may file a dental malpractice claim. Dental negligence may result in harmful consequences, especially during surgical procedures. Any deviation from the standard of care can constitute malpractice. For example, a dentist (or dental hygienist) may deliver subpar care, delay treatment, or act in various ways beneath an acceptable dental standard.
Common reasons someone may file a dental malpractice case include:
- Infections
- Anesthesia complications
- Oral-nerve injuries
- Failure to diagnose or treat a condition
- Lack of informed consent
- Misdiagnosis
- Delayed treatment
Wrongful, delayed, or failed diagnosis
One of the most common types of dental malpractice lawsuits involves the wrongful or delayed diagnosis of a patient. In such cases, these delayed or erroneous diagnoses can lead to injury, unnecessary treatments and medical expenses, and death.
In addition, a dentist (or dental hygienist) who overlooks obvious oral health issues or fails to diagnose such an issue may be held liable for resulting injuries or health issues. A dental practitioner has a duty of care toward their patients. This duty of care is undermined when the practitioner acts in any way that’s considered negligent or appears to disregard the life and health of their patient.
SOAP notes have been used in medicine for years. It’s clearly in our best interest as a profession to adapt a SOAP note template to use in our practices. As the dental hygienist, if your office is not using some form of standardized documentation, how willing are you to develop and present this important aspect of clinical risk prevention to your coworkers?
Basic Comprehensive Exam template
COMP EXAM (soft or hard tissue) with Dr. (First and Last Name)
SUBJECTIVE
A _______ year old (nationality) (preferred gender) presents for comprehensive exam.
Chief concern: Why are they there that day?
Medical HX: List in order of severity
Patient denies all other cardiovascular, pulmonary, renal, hepatic, thyroid, diabetic, osteoporosis, joint replacement, GI, and cancer conditions.
Current medications: In same order of corresponding medical conditions
Allergies: True allergies only (rash, anaphylactic reaction); can list adverse reactions such as GI upset but label as such
Dental HX:
LDV: Last dental visit -date and reason for visit
Hx of SRP: Which quadrants completed and date
Brushes:
Flosses:
Mouthwash:
Social HX:
Tobacco use:
EtOH use:
Recreational drug use:
PARQ: Patient informed of today's Procedure, Alternatives, Risks, and all Questions were answered. Verbally obtained consent.
OBJECTIVE:
Vitals
BP:
HR:
RR:
Data collection
*Critical: EO/IO findings and gingival descriptions—can insert individual office templates here. If a lesion is not documented, it could be charged you never completed the EO/IO and failed to diagnose a potential issue
Assessment: Your hygiene periodontal DX based on the stage and grade
*Critical: If it is not documented, you never completed the exam and therefore, failure to diagnose could be charged
Periodontal prognosis: Based on McGuire's criterion
Good:
Fair:
Poor:
Questionable:
Hopeless:
PLAN/PROCEDURE:
Completed Comp Exam (soft or hard tissue). Reviewed and updated medical/dental/social hx. Vitals taken. Performed EO/IO exam, periodontal assessments, and completed all periodontal charting to include probing, BOP, recession, furcations, and mobility. Discussed findings with patient and answered all questions. (Add any additional notes that are necessary here.) Patient left clinic in good condition.
Provider signature
Next visit: Reason for appointment and length of time to block
You may want to add additional templates for SRP (scaling and root planning), SPG (scaling in the presence of gingivitis), Periodic Exams, and Periodontal Maintenance. I also recommend a hard tissue template for the dentist that includes existing teeth and restorations, CAMBRA (Caries Management by Risk Assessment), STOPBANG findings (Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender), and other issues relevant to the hard tissue exam.
Remember: It protects you
Although it is common for dental hygienists to be legally covered under the umbrella of the DDS or office malpractice insurance policy, there are more cases being presented to dental boards that include the dental hygienist.
Remember, the number one way to protect yourself and your practice is to document, document, document. Using a SOAP note for each patient encounter protects you if you’re requested to defend yourself in a legal proceeding. Be sure to also have a template to document all missed or late appointments as those also affect patient care and outcomes.
