Dental SOAP notes: template and example
A practical SOAP note template for dentistry, a worked example, and what belongs in each section so the record stands up later.
Applies to: Any practice
Chairscribe drafts; the clinician reviews and signs. Every entry in the patient record remains yours.
A dental SOAP note records an appointment in four sections: Subjective (what the patient reports), Objective (what you find), Assessment (your diagnosis), and Plan (what happens next). The structure keeps notes complete and defensible, and it is the most widely used clinical note format in dentistry.
What goes in each section
| Section | What it holds | Dental examples |
|---|---|---|
| Subjective | The patient’s words: complaint, history, symptoms | Chief complaint, pain history, medical history changes, medications |
| Objective | What you observe and measure | Clinical findings, radiographic findings, perio readings, existing restorations |
| Assessment | Your professional interpretation | Diagnosis, differential, prognosis |
| Plan | What was done and what comes next | Treatment provided today, materials used, consent, post-op instructions, next visit |
A dental SOAP note template you can copy
S: Chief complaint. Pain history (site, onset, character, aggravating factors). Relevant medical history and medications. Changes since last visit.
O: Extra-oral findings. Intra-oral findings. Tooth/teeth examined, surfaces, existing restorations. Radiographs taken and findings. Perio status. Special tests (percussion, vitality, mobility).
A: Diagnosis. Differential if applicable. Prognosis.
P: Treatment provided today, including anaesthetic (agent, dose), materials and shades. Consent discussed and obtained. Post-op instructions given. Planned next visit and treatment.A worked example
S: Pt reports intermittent sharp pain upper left when chewing, 2 weeks. No temperature sensitivity. Medical history reviewed, no changes. No regular medications.
O: 26 large MOD amalgam with fracture line across distal marginal ridge. No swelling or sinus. 26 responds normally to cold; tender to percussion. PA radiograph 26: no periapical pathology, restoration close to pulp distally.
A: Cracked tooth 26, symptomatic. Pulp vital. Guarded prognosis for the distal cusp.
P: Discussed findings and options (cuspal coverage restoration vs monitor). Pt elected onlay. Verbal and written consent obtained. LA: articaine 4% 1:100,000 adrenaline, 2.2 ml buccal infiltration. Prepared 26, immediate temporisation. Post-op instructions given verbally. Next visit: cementation, 2 weeks.Tips for SOAP notes that hold up
- Write in the patient’s own words in S where it matters. “Throbbing since Tuesday” beats “pain”.
- Keep A honest. If the diagnosis is provisional, say so.
- P should let a colleague pick up the case cold: what was done, with what, and what happens next.
- Record consent every time it is discussed, not just for big-ticket items.
Stop filling the template by hand
The template solves structure, but you are still typing the content. An AI dental scribe fills your SOAP template from the appointment conversation itself: the patient’s complaint lands in S, your narrated findings in O, and your stated plan in P, ready for your review and sign-off. You can build your own templates too; start with creating templates: the basic guide.
Start scribing to see your next appointment come out as a finished SOAP note, free for 14 days.