DentalCare

DentalCare

DentalCare

DentalCare

DentalCare
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The Business of Dentistry: Patient Records and Records Management

Natalie Kaweckyj, LDARF, CDA, CDPMA, COA, COMSA, CPFDA, CRFDA, MADAA, BA; Wendy Frye, CDA, RDA, MADAA; Lynda Hilling, CDA, MADAA; Lisa Lovering, CDA, CDPMA, MADAA; Linette Schmitt, CDA, RDA, MADAA; Wilhemina Leeuw, MS, CDA

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The patient chart is a legal record of dental services.  Information noted must be accurate, comprehensive, concise and current.  During an initial oral exam, data recorded includes conditions present and any previous dental treatment provided.  Dental SOAP notes are written to improve communication among all those caring for the patient by standardizing evaluation entries made in dental charts.  Each letter in "SOAP" is a specific heading in the notes:

S – refers to subjective, the purpose of the patient’s dental visit.  This section also includes the description of symptoms in the patient’s own words including:  pain, what triggers the discomfort, what causes the discomfort to disappear and the length of time these symptoms have been occurring.

O – refers to objective, unbiased observations by the dental team.  Included under this heading would be things that can actually be felt, heard, measured, seen, smelled and touched.

A – refers to assessment, the diagnosis of the patient’s condition done by the dentist.  The diagnosis may be clear or there may be several diagnostic possibilities.

P – refers to the plan or proposed treatment, and is decided upon by the patient and the dentist.  The plan may include radiographs, medications prescribed, dental procedures, patient referral to specialists and patient follow-up care instructions.

A SOAP notation is not supposed to be as detailed as a progress report and the usage of abbreviations is standard.  Abbreviations will vary slightly from one practice to another, so it is important to use notations commonly used within the practice.  It is imperative that the individual making the notation sign their name and list their credentials so that those reading the record know who was responsible for the notes.  Notes should be free from scribbles and whiteout errors.  If an error is made, a single line should be drawn through the error, dated and initialed, and the correction written.  Corrections in computerized formats will vary according to dental software.  Notations should be written fluently and without blank lines between the entries.  This will prevent additional information being added without the writer’s knowledge.

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