To give patients the full benefit of your dental care, much depends on one thing: the content of your clinical notes. Using the SOAP note format streamlines your workflow and clarifies facts for others such as healthcare providers and insurance payers.
What is a soap note? SOAP stands for subjective, objective, assessment, and plan. SOAP notes are a great way to quickly capture important clinical details in an organized way. Using this format helps you easily communicate information for insurance claims, other caregivers, your patients, and your own legal protection.
And the best part? The SOAP notes are easy to implement once you know what they contain.
DCS is a full-service dental billing partner that helps your team collect revenue easily. Our award-winning services have streamlined billing processes for dental teams all over the US.
That’s why we’re sharing this article with you: to explain to you what SOAP documentation is, and why streamlining your documentation process will lead to quicker reimbursement from insurance claims.
And in turn, you’ll have higher collections instead of being at the whims of insurance companies.
What does SOAP notes stand for?
SOAP documentation stands for Subjective, Objective, Assessment, and Plan. Let’s dive a little deeper into what each section means for your documentation.
1. Subjective: This is the information that the patient gives you directly. For example, they might come in with a toothache. Their description of the pain and where it is would go under the “Subjective” section. This can also include their dental history, and any medications they might be taking.
2. Objective: This is the information you gather yourself, as a dental professional. This will include any intraoral or extraoral observations, radiology, or anything else very specific to their oral health that a patient wouldn’t see or know how to describe.
3. Assessment: This is where you complete a diagnosis based on the information and data you’ve gathered. You’ll also include a prognosis.
4. Plan: This is the section in which you will document the agreed-upon plan with your patient and the dentist after they’ve been diagnosed. This can include a treatment that was discussed and/or actually performed that day.
Each of these sections in the template makes it easy for your team to document the more important information to include on your insurance claim and for your patient’s records.
Keep in mind: When you use templates, make sure you are always modifying it to include all of the patient’s information. Don’t paste in previous patient information, as it is likely incorrect, and not relevant to the details of your current patient.
Related: Using a dental clinical notes template: Pros and cons
Example of SOAP notes
S = Subjective - how the patient describes symptoms, concerns
- Chief complaint from the patient
- History of present illness (HPI)
- History
- Medical history, surgical history (with year), family history, and social history
- Review of symptoms
- Medications, allergies
O = Objective - Findings from measurements and examination
- Vital signs
- Clinical examinations
- Intraoral
- Extraoral
- Laboratory test results
- Imaging results
- PA, pano, CT
A = Assessment - diagnosis of condition(s)
- Patient’s condition diagnosed by the doctor
- Example: Distal occlusal caries on #30
- Dental hygiene diagnosis
P = Plan - Treatment for the patient’s concerns
- Procedures performed
- Medications given
- Education provided
- Referrals if given
This is an example of what to include in each section of your SOAP notes. This will show you what kind of information would be included in SOAP notes, and where they would go.
Work smarter, not harder when it comes to record-keeping at your dental practice
So why is SOAP documentation recommended for your record-keeping? Well, for starters it’s simple to fill out and follow. And clearly, the theme of this article is working efficiently to make your work feel easier. Not to mention, working this way will help you get paid quickly by insurance.
Templates used for any kind of clinical notes should be viewed as a checklist. This means your documentation should include but not be limited to what is listed on the template. Having SOAP notes helps you remember exactly what to include.
There’s so much to remember when moving through the dental billing process that having a SOAP template can save you a lot of time and effort.
Proper documentation: The key to success at every dental practice
Documentation is paramount when keeping your records, but also for insurance claim submission. Your documentation is proof that treatment was needed. When you properly fill out your SOAP notes, you can refer to them if the patient ever has questions about their past treatment.
Related: Why attachments are important in dental insurance claims
But you can also be sure you’re including relevant and detailed information in your insurance claims. The more accurate and detailed information you can include in your claim documentation and attachments, the quicker they will be approved and you will be paid.
Being able to easily refer to your SOAP documentation for insurance claims or patient questions is a great way to stay organized and streamlined in your dental office.
Ready to learn more about best practices when it comes to your billing and documentation?
SOAP documentation is a great way to confidently keep track of patient records, and use that information in your insurance claims. This will lead to more organized record keeping and more accurate claims, leading to quicker payment from insurance.
Our educational platform, DCA (Dental Claims Academy) has a course dedicated specifically to documentation, including applying SOAP documentation at your dental practice.
You can also have someone handle the streamlining of your dental billing process for you. DCS billers work to help you streamline your billing processes. To learn more about streamlining your billing and taking control of how quickly you are paid by insurance companies, schedule a call with one of our billing experts.
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