Dental Hygiene Soap Note

SOAP Note

Prepared by:

Sarah C. Lemay

Streamline Strategies

Date: March 3, 2050

This SOAP Note provides a structured approach towards documenting the essentials of the dental hygiene visit of Mr. William Wright, a 50-year-old male with specific dental concerns. The information documented consists of subjective observations, objective measurements, the assessment, and devised plan for treatment.

Subjective

Objective

Assessment

Plan

- Complaints of tooth sensitivity to hot and cold.
- Reports occasional discomfort while chewing.
- History of irregular dental cleaning.

- Patient is 50 years old, male, 195lbs, height: 6'0".
- Oral examination revealed plaque accumulation and gum inflammation.
- Some teeth showed enamel erosion.

- The individual displays signs indicative of mild periodontitis and dental erosion which could be instigating the symptoms.
- Need for improvement in dental hygiene habits is evident.

- Recommend commencement of treatment for periodontitis including deep cleaning.
- Schedule follow-up after treatment to monitor progress.
- Provide education and instruction for proper dental hygiene habits.

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