This would include the EO/IO (extraoral/intraoral) findings, periodontal probing along with furcations, mobility, recession, CAL (clinical attachment loss), and BOP (bleeding on probing). “O” is the objective data that you gathered. A better choice of words might be, “Since you were here in January of 2022, have you visited your doctor and what for? I am about to review the medications we have on file so please let me know if you have any changes to add or delete, or a dosage change. Note: We do not recommend asking the question, “Any changes to your health or medications?” This is too broad, and many patients don’t realize the importance of or remember since their last visit. Examples are why they are there (not a good idea to complete a prophy when they thought they were there for a restoration), medical history information, medications and dosages, allergies, dental history, social history, consent, and vitals (this could possibly go under “O” but we always ask if they know what their numbers typically run, especially if they’re out of range). This is the information the patient provides to you. I have edited it to be more useful to practicing dental hygienists. SOAP notes have been used in medicine for years while there are numerous templates, the one I've shared below is what I find most useful in helping document findings.
Moving forward some 30 years, I now regularly use a SOAP note format. Abbreviations were common and occupied less space on the written document. My soft tissue note read something like: Med HX, OCE-neg, and gingivitis. My usual entry looked like this: pro, fltx, 4 BWs, ex. In fact, because we used paper charts, I was told that I could only use one to two lines to document my work. Years ago, when I was a new hygienist, it was not uncommon for me to write up very brief notes.
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