Chart entries for initial visits, periodic evaluations, and emergency visits are well understood and legally complete if done in the form of a SOAP note. Subsequent treatment visits do not need such detail

S=Subjective--- what the patient tells you
Patients chief complaint, history of present illness (this complaint)
Past medical history, past dental history

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 toi smoking 1/2 pack per day of cigarettes. Past dental history: Patient receives dental cleanings irregularly, does not use floss.

O=Objective--- what you see in your examination, including radiographic

Example:Intra-oral exam reveals tongue, palate, FOM WNL. Gingiva is pink and stippled with localized swelling and redness in lower anterior and maxilla posterior regions. Pocketting and dentition 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 in occlusal pits maxillary premolars, however bite-wing radiographs reveal no sign of decay. #31 with large IRM. Radiographic exam reveals IRM #31 is close to pulp. Bone loss seen in area of #23-26.

A=Assessment-- problem list, or diagnoses. It works well to number these and make corresponding remarks in the '"'Plan'"' section.

Example:
1) Missing #7
2) Localized periodontal disease #23-26
3) #31 restoration close to pulp, poss. pulpal pathology
4) Max. premolars non-carious

P=Plan-- what you plan to do, and what you did today. Try to address each problem.

Example:
Today: Examination, full mouth series radiographs taken and read. Alg. imps for study
1) Explained to patient that there are several different ways to restore missing #7. Will review study casts and discuss options and fees at next appointment.
2)Expl'd to patient need for more frequent prophys, and the use of floss.
3)Will eval pulpal status of #31 with endodontic consult
4)Recommend no treatment for occlusal fissures of premolars
RTC (Return to clinic) Discuss treatment plan options.