Pediatric Dental Exam & SOAP Notes

Encounter

Encounter header

No patient identifiers are collected or stored.

Age (years)not documented

Additional monthsnot documented

Use for infants and toddlers.

Sexnot documented

Exam typenot documented

Presents withnot documented

Chief concernnot documented

Subjective / History

Medical history

Medical historynot documented

Medicationsnot documented

Allergiesnot documented

Surgeriesnot documented

Hospitalizationsnot documented

Previous anesthesia / sedation complicationnot documented

Special health care / developmental considerationsnot documented

Current dental concerns

Current dental concernsnot documented

Dental history

Previous dental carenot documented

Previous treatmentnot documented

Previous dental experiencenot documented

Trauma historynot documented

TMJ symptomsnot documented

Home oral hygiene

Brushingnot documented

Who brushesnot documented

Toothpastenot documented

Flossing / interdental cleaningnot documented

Fluoride exposure

Primary drinking waternot documented

Fluoridation statusnot documented

Supplemental / home fluoridenot documented

Recent fluoride varnish applicationnot documented

Professional varnish applied within roughly the last 6 months.

Diet

Between-meal sugar-containing exposuresnot documented

Sugar / cariogenic beverage patternnot documented

Beverage typesnot documented

Grazingnot documented

Sticky / retentive carbohydrate exposurenot documented

Food / caloric beverage after bedtime brushingnot documented

Orofacial habits

Habitsnot documented

Airway / sleep screen

Snoringnot documented

Mouth breathingnot documented

Witnessed breathing pausesnot documented

Restless sleepnot documented

Daytime sleepiness / behavioral concernsnot documented

Prior tonsil / adenoid evaluation or surgerynot documented

Objective Examination

Extraoral

Extraoral examinationnot documented

Intraoral soft tissue

Intraoral soft tissuenot documented

Oral hygiene / periodontal

Oral hygienenot documented

Plaque / biofilmnot documented

Calculusnot documented

Gingival tissuesnot documented

Additional periodontal findingsnot documented

Dentition

Dentitionnot documented

Eruptionnot documented

Radiographs

Radiographs this visitnot documented

Hard tissue / caries

Affected teethnot documented

One card per tooth — clinical, radiographic, and pulpal findings together.

Tooth

Clinical finding

Radiographic finding

Pulpal / periradicular assessment

Or document without tooth-level chartingnot documented

Occlusion / developing dentition

Overallnot documented

Behavior

Frankl behavior ratingnot documented

Behavior guidance used todaynot documented

Cooperation notes

Caries risk

Suggested caries risk

Age-appropriate factor set: age not documented. This is a suggestion only — the clinician sets the final risk.

Insufficient data

• Insufficient documented information to suggest a risk level.

Documented factors

Risk & clinical factors

None documented.

Disease indicators

None documented.

Protective factors

None documented.

Clinician final caries risk

Assessment

Nothing below enters the note until you confirm it. Suggestions are generated from documented findings only.

Add a diagnosis

Guidance

Only items marked Discussed appear in the note. Suggested items that were not acted on are never documented.

Additional counseling actually provided

Preventive procedures

Prophylaxis

Fluoride varnish

Sealants

Specify teeth in treatment notes.

Oral hygiene instruction

Dietary counseling

SDF application

Findings reviewed with caregiver

Treatment & recall

Treatment options are considerations only. Nothing is auto-selected, and advanced behavior guidance is never recommended automatically.

Preventive

No operative treatment indicated at this timeNo caries documentedPreventive sealants on susceptible permanent molarsCaries-susceptible surfaces

Behavior / treatment setting

Recall

Periodic recall, focused follow-up, and next visit are separate concepts.

Periodic recall interval

Focused follow-up

Next visit

Referral considerations

Patient presents for dental examination.

=== SUBJECTIVE ===

Fluoride Exposure:
- Recent fluoride varnish application: Not documented.

=== OBJECTIVE ===

- Not documented.

=== ASSESSMENT ===

Diagnoses:
- Assessment pending clinician confirmation.

=== PLAN ===

- Not documented.

Documentation check — 55 items not documented

• Encounter header: Age (years)
• Encounter header: Additional months
• Encounter header: Sex
• Encounter header: Exam type
• Encounter header: Presents with
• Encounter header: Chief concern
• Medical history: Medical history
• Medical history: Medications
• Medical history: Allergies
• Medical history: Surgeries
• Medical history: Hospitalizations
• Medical history: Previous anesthesia / sedation complication
• Medical history: Special health care / developmental considerations
• Current dental concerns: Current dental concerns
• Dental history: Previous dental care
• Dental history: Previous treatment
• Dental history: Previous dental experience
• Dental history: Trauma history
• Dental history: TMJ symptoms
• Home oral hygiene: Brushing
• Home oral hygiene: Who brushes
• Home oral hygiene: Toothpaste
• Home oral hygiene: Flossing / interdental cleaning
• Fluoride exposure: Primary drinking water
• Fluoride exposure: Fluoridation status
• Fluoride exposure: Supplemental / home fluoride
• Fluoride exposure: Recent fluoride varnish application
• Diet: Between-meal sugar-containing exposures
• Diet: Sugar / cariogenic beverage pattern
• Diet: Beverage types
• Diet: Grazing
• Diet: Sticky / retentive carbohydrate exposure
• Diet: Food / caloric beverage after bedtime brushing
• Orofacial habits: Habits
• Airway / sleep screen: Snoring
• Airway / sleep screen: Mouth breathing
• Airway / sleep screen: Witnessed breathing pauses
• Airway / sleep screen: Restless sleep
• Airway / sleep screen: Daytime sleepiness / behavioral concerns
• Airway / sleep screen: Prior tonsil / adenoid evaluation or surgery
• Extraoral: Extraoral examination
• Intraoral soft tissue: Intraoral soft tissue
• Oral hygiene / periodontal: Oral hygiene
• Oral hygiene / periodontal: Plaque / biofilm
• Oral hygiene / periodontal: Calculus
• Oral hygiene / periodontal: Gingival tissues
• Oral hygiene / periodontal: Additional periodontal findings
• Dentition: Dentition
• Dentition: Eruption
• Radiographs: Radiographs this visit
• Hard tissue / caries: Affected teeth
• Hard tissue / caries: Or document without tooth-level charting
• Occlusion / developing dentition: Overall
• Behavior: Frankl behavior rating
• Behavior: Behavior guidance used today

Blank means not documented — it is never reported as normal.

Patient presents for dental examination.

=== SUBJECTIVE ===

Fluoride Exposure:
- Recent fluoride varnish application: Not documented.

=== OBJECTIVE ===

- Not documented.

=== ASSESSMENT ===

Diagnoses:
- Assessment pending clinician confirmation.

=== PLAN ===

- Not documented.

Documentation check — 55 items not documented

• Encounter header: Age (years)
• Encounter header: Additional months
• Encounter header: Sex
• Encounter header: Exam type
• Encounter header: Presents with
• Encounter header: Chief concern
• Medical history: Medical history
• Medical history: Medications
• Medical history: Allergies
• Medical history: Surgeries
• Medical history: Hospitalizations
• Medical history: Previous anesthesia / sedation complication
• Medical history: Special health care / developmental considerations
• Current dental concerns: Current dental concerns
• Dental history: Previous dental care
• Dental history: Previous treatment
• Dental history: Previous dental experience
• Dental history: Trauma history
• Dental history: TMJ symptoms
• Home oral hygiene: Brushing
• Home oral hygiene: Who brushes
• Home oral hygiene: Toothpaste
• Home oral hygiene: Flossing / interdental cleaning
• Fluoride exposure: Primary drinking water
• Fluoride exposure: Fluoridation status
• Fluoride exposure: Supplemental / home fluoride
• Fluoride exposure: Recent fluoride varnish application
• Diet: Between-meal sugar-containing exposures
• Diet: Sugar / cariogenic beverage pattern
• Diet: Beverage types
• Diet: Grazing
• Diet: Sticky / retentive carbohydrate exposure
• Diet: Food / caloric beverage after bedtime brushing
• Orofacial habits: Habits
• Airway / sleep screen: Snoring
• Airway / sleep screen: Mouth breathing
• Airway / sleep screen: Witnessed breathing pauses
• Airway / sleep screen: Restless sleep
• Airway / sleep screen: Daytime sleepiness / behavioral concerns
• Airway / sleep screen: Prior tonsil / adenoid evaluation or surgery
• Extraoral: Extraoral examination
• Intraoral soft tissue: Intraoral soft tissue
• Oral hygiene / periodontal: Oral hygiene
• Oral hygiene / periodontal: Plaque / biofilm
• Oral hygiene / periodontal: Calculus
• Oral hygiene / periodontal: Gingival tissues
• Oral hygiene / periodontal: Additional periodontal findings
• Dentition: Dentition
• Dentition: Eruption
• Radiographs: Radiographs this visit
• Hard tissue / caries: Affected teeth
• Hard tissue / caries: Or document without tooth-level charting
• Occlusion / developing dentition: Overall
• Behavior: Frankl behavior rating
• Behavior: Behavior guidance used today

Blank means not documented — it is never reported as normal.