This document provides commonly used medical abbreviations for patient records in hospitals and dental offices. It lists abbreviations for items like patient, years old, medical, history, no known drug allergies, cigarettes, on examination, and more. It also describes the SOAP note structure as Subjective, Objective, Assessment, Plan used to organize clinical notes. An example SOAP note is then provided documenting a dental visit for a patient complaining of severe pain in tooth #26.

1. Useful Abbreviations
SOAP
• Pt Patient
• YO Years Old
• Med. Medical
• Hx History
• NKDA No Known Drug Allergies
• Cig. Cigarettes
• O/E On Examination
• EOE Extra-Oral Examination
• IOE Intra-Oral Examination
• Tx Treatment
The SOAP system is • ē
With
designed to organize • Tab. Tablet
and simplify noting in • Cap. Capsule
hospital and office • PRN As needed
settings. • Q6H Every 6 hours
•
Male
•
Female
Subjective, Objective, 1.Write a brief history: Patient’s age, Nationality, Gender, Past medical history, Habits,
and Past dental history.
Assessment, Plan; 2.Start with S: Subjective, Symptoms, Chief Complaint, History of present illness.
3.Next is O: What clinical and radiographic examination reveals.
SOAP
4.Then A: Assessment, Problem list, Diagnosis. The list is better be numbered and
corresponding numbers in the “Plan” section are made.
5.Finally P: Plan of the treatment, What is going to be done today, and in the Next Visit.
Hx22 yo Saudi , Student. Med
Pt is
Example
•
•
Missing t#24.
Slight drifting of t#23, 25
lidocaine ē 1:100k adrenaline in the
area of t#26.
into space of missing t#24. • R.D. Was applied, single
Hx is not significant. NKDA. Not
• Radiographically: isolation.
using any drugs. Smoker 1/2 pack a
• T#26, widening of the • Caries was removed using a
day of cig. Dental Hx includes several
PDL space, and a well small diamond round bur.
restoration, RCT and extraction.
defined, corticated • Access cavity was made.
S CC: "I left lastsevere pain in the
radiolucent lesion 1x1 • Canals were identified (P, DB,
have my
A
cm were detected. MB I, MB II).
upper tooth (T#26),
• Pulp extirpation was done using
pain is spontaneous and it started 2
1. T#26, Caries, Irreversible pulpitis, and a barbed broach #15.
days ago, it is better when I take
Acute Apical Abscess. • WL was determined using the
Panadol, and I want to fix all my
2. Generalized Moderate Plaque- apex locator and confirmed
teeth".
induced gingival disease. radiographically, (P: 20 mm, DB:
O 3.
4.
RR of t#46.
Caries in t#16, 26, 34.
19 mm, MB I: 19 mm, and MB II:
18 mm).
• EOE:
5. Missing t#24. • Instrumentation was made ē K-
• Lymph nodes, TMJ, Skin,
files #15, #20, and #25.
• IOE:
Lips, and Face all WNL.
P • Intra-canal medicament (CaOH)
1. RCT and cusp coverage. was applied.
• T#26 Thermal test revealed
2. Scaling and polishing. • 2 cotton pellets were placed.
lingering pain response
3. Extraction of the RR of t#46. • The cavity was sealed using
(CO2).
4. Removal of caries and restoration of metal-reinforced glass ionomer
• T#26 is tender to palpation
t#16, 34. cement.
and percussion.
5. Implant or FPD in the space of • Pt was instructed to:
• Moderate plaque
missing t#24. • Improve OH.
accumulation, Generalized
• Take Ibuprofen 400 mg tab.
gingival inflammation, BOP,
Loss of stippling, Slight Today Q6H PRN x3 days.
redness, and Edema (see
chart).
• Explained the tx to the patient. N.V.
• Infiltration anesthesia was Instrumentation and obturation of the
• RR of t# 46.
administered, 2 carpules 2% canals.
• Caries in t#16, 26, 34.
Dr. Omar Hamad AlKadhi, RCsDP
Omar.H.AlKadhi@gmail.com