Free Printable Dental SOAP Note Template

Printable Dental SOAP Note

S: Subjective

  • Chief Complaint: Patient reports toothache in the upper right quadrant for 3 days.

  • Medical History: No known allergies, non-smoker, diabetic.

  • Pain Scale: 6/10.

O: Objective

  • Visual Inspection: Swelling noted around tooth #2.

  • Palpation: Tenderness in the upper right jaw.

  • Radiographs: X-ray shows possible caries on tooth #2.

  • Vital Signs: BP 130/80, Pulse 72, Respiration 16, Temperature 98.6°F.

A: Assessment

  • Diagnosis: Acute pulpitis (tooth #2).

  • Differential Diagnosis: Periapical abscess, Gingivitis.

P: Plan

  • Treatment:

    1. Perform root canal therapy on tooth #2.

    2. Prescribe Amoxicillin 500mg, 3 times a day for 7 days.

    3. Schedule follow-up in 1 week.

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