SOAP Note
Also written as: SOAP — Subjective, Objective, Assessment, Plan
A structured clinical documentation format comprising Subjective, Objective, Assessment, and Plan sections, used in dental hygiene appointment records.
Full Definition
The SOAP note (Subjective, Objective, Assessment, Plan) is a standardized documentation framework adapted from medicine and used in dental hygiene to record patient encounters in a clear, legally defensible format. The Subjective section captures the patient's reported concerns; the Objective section records clinical findings such as vital signs, probing depths, and radiographic observations; the Assessment section contains the dental hygiene diagnosis and risk categorisation; and the Plan section outlines treatment provided and future recommendations. Editors must ensure that SOAP is always rendered as a four-letter acronym in capital letters and that the headings within the note mirror the correct sequence. In some jurisdictions or settings, a fifth element — Evaluation — is added, producing a 'SOAPE note'.
Usage
Usage note: Always render 'SOAP' in all capitals. Confirm whether the institutional standard includes an Evaluation section (SOAPE) before finalising document templates.
In Context
- "The SOAP note for the appointment included a subjective complaint of tooth sensitivity, objective findings of 4 mm recession on teeth #22–24, a dental hygiene diagnosis of dentinal hypersensitivity risk, and a plan for fluoride varnish application." — Dental hygiene clinical record
- "Ensure all SOAP note headings (Subjective, Objective, Assessment, Plan) are bold and consistently formatted across every patient record in the appendix." — Clinical records editing note