Dental SOAP Template

Purpose of the Visit

[State the reason the patient came in for the dental consultation or treatment.]

Chief Complaint (CC)

[Describe the primary concern or symptom reported by the patient in their own words.]

Medically Significant Findings

[Note any relevant medical history, allergies, or systemic conditions that may affect dental treatment.]

Extra-Oral Examination (Head and Neck)

[Document any findings related to facial symmetry, lymph nodes, temporomandibular joint (TMJ), and other notable extra-oral features. If no information present in transcript, remove this section]

Facial Profile – Skeletal and Dental

[Assess and describe the skeletal pattern (Class I, II, III) and dental alignment or malocclusion. If no information present in transcript, remove this section]

Space Analysis – Deficiency or Excess

[Record any discrepancies in arch space, including crowding or spacing. If no information present in transcript, remove this section]

Intra-Oral Soft Tissue Examination

[Observe and note the condition of soft tissues such as gingiva, tongue, mucosa, periodontal charting, and palate. If no information present in transcript, remove this section]

Other Relevant Findings

[Include any additional intraoral findings, habits, occlusal issues, or anomalies. If no information present in transcript, remove this section]

Assessment & Plan

[Create a numbered list of dental conditions reviewed and treatment provided. Also include future treatment suggestions, follow-up plans, or referrals to specialists as needed. List any pamphlets or informational materials provided.] (For example - 1. Dental Caries - • Amalgam restorations are placed on teeth 47 mesial occlusal, 46 distal occlusal, and 15 distal occlusal. • Composite restoration is placed on tooth 23 facial. • No post-operative complications are noted. • Schedule a six-month recall examination for follow-up.)