The problem-oriented record (POR) focuses on problems requiring treatment rather than on traditional diagnoses. It stresses the importance of complete and accurate collecting of clinical data, with the emphasis on recording abnormal findings, rather than on compiling the extensive lists of normal and abnormal data that are characteristic of more traditional methods (consisting of narration, checklists, questionnaires, and analysis summaries). Problems can be subjective (symptoms), objective (abnormal clinical signs), or otherwise clinically significant (eg, psychosocial) and need not be described in prescribed diagnostic categories. Once the patient’s problems have been identified, priorities are established for further diagnostic evaluation or treatment of each problem. These decisions (or assessments) are based on likely causes for each problem, risk analysis of the problem’s severity, cost and benefit to the patient as a result of correcting the problem, and the patient’s stated desires. The plan of treatment is formulated as a list of possible solutions for each problem. As more information is obtained, the problem list can be updated, and problems can be combined and even reformulated into recognized disease categories.
The POR is helpful in organizing a set of complex clinical data about an individual patient, maintaining an up-to-date record of both acute and chronic problems, ensuring that all of the patient’s problems are addressed, and ensuring that preventive as well as active therapy is provided. It is also adaptable to computerized patient-tracking programs. However, without any scientifically based or accepted nomenclature and operational criteria for the formulation of the problem list, data cannot be compared across patients or clinicians.
Despite these shortcomings, two features of the POR have received wide acceptance and are often incorporated into more traditionally organized records—the collection of data and the generation of a problem list. In dentistry, the value of the POR has been documented in orthodontics and hospital dentistry but otherwise appears to have attracted little attention in dental education.
The value of a problem list for individual patient care is generally acknowledged,
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and it is considered a necessary component of the hospital record in institutions accredited by the Joint Commission on Accreditation of Healthcare Organizations.
The four components of a problem—subjective, objective, assessment, and plan (SOAP)—are widely taught as the SOAP mnemonic for organizing progress notes or summarizing an outpatient encounter. The components of the SOAP mnemonic are as follows:
SSubjective: the patient’s complaint, symptoms, and medical history (a brief review)
OObjective: the clinical examination, including a brief generalized examination, as previously described, and then a focused evaluation of the chief complaint or the area of the procedure to be undertaken
AAssessment: the diagnosis (or differential diagnosis) for the specific problem being addressed
P Plan: the treatment either recommended or performed The SOAP note is a useful tool for organizing progress notes in the patient record for routine office procedures and follow-up appointments. It is also quite useful in a hospital record when a limited oral medicine consultation must be documented. An example of each type of SOAP note is shown below.
Example 1: Routine Office Procedure. S: This 21-year-old female presented for routine extraction
of the maxillary right first molar. As found by history, the tooth “broke in half ” while the patient was chewing ice. The patient had been in pain since the tooth fractured 24 hours ago. The discomfort was sharp, constant, and was exacerbated with cold and mastication. Past medical history was unremarkable. The patient was taking no medication and had not been seriously ill or hospitalized since her last visit 6 months ago.
O: The patient was afebrile, and her blood pressure (BP) and pulse were normal (BP = 110/70 RASit [right arm sitting]; pulse = 72 reg [regular rhythm]). There was no swelling or adenopathy. The maxillary right first molar was vertically fractured through the central fossa and progressed into the furcation.
A: Irreversible pulpitis, vertical fracture, nonrestorable. P: Extraction, using a local anesthetic of 1.8 cc of 3% car-
bocaine infiltration. The tooth was extracted with forceps without incident. The patient tolerated the procedure well; advised to take acetaminophen as necessary for discomfort. Postoperative instructions were given. The patient will return in 7 days for follow-up.
Example 2: Follow-Up Appointment. S: The patient returned 1 week after routine extraction of
the maxillary right first molar. The patient reported uneventful healing and was “surprised” at how well she felt.
O: No palpation tenderness or suggestion of bleeding or infection. Mucosal color at the extraction site was normal.
A: Healing normally. P: The patient is to be scheduled to discuss prosthetic
replacement of this tooth.
Example 3: Limited Oral Medicine Consultation. S: A 55-year-old male who is an inpatient for reconstruc-
tive knee surgery, due to a skiing accident. The patient has had a recent onset of oral ulceration; he has also complained of gastrointestinal distress. There is no previous history of similar oral ulceration or gastrointestinal disease. The patient is in ASA class I and is not presently taking any medication except for ibuprofen (800 mg) given as an analgesic postsurgically.
O: Classic aphthalike ulcerations of the buccal and labial mucosae and lateral tongue borders. The largest lesion is 0.6 cm in diameter. The total number of lesions is six.
A: Erythema multiforme secondary to ibuprofen therapy. P: Recommend that attending physician discontinue the
use of ibuprofen and substitute acetaminophen, as necessary for analgesia.
of the maxillary right first molar. As found by history, the tooth “broke in half ” while the patient was chewing ice. The patient had been in pain since the tooth fractured 24 hours ago. The discomfort was sharp, constant, and was exacerbated with cold and mastication. Past medical history was unremarkable. The patient was taking no medication and had not been seriously ill or hospitalized since her last visit 6 months ago.
O: The patient was afebrile, and her blood pressure (BP) and pulse were normal (BP = 110/70 RASit [right arm sitting]; pulse = 72 reg [regular rhythm]). There was no swelling or adenopathy. The maxillary right first molar was vertically fractured through the central fossa and progressed into the furcation.
A: Irreversible pulpitis, vertical fracture, nonrestorable. P: Extraction, using a local anesthetic of 1.8 cc of 3% car-
bocaine infiltration. The tooth was extracted with forceps without incident. The patient tolerated the procedure well; advised to take acetaminophen as necessary for discomfort. Postoperative instructions were given. The patient will return in 7 days for follow-up.
Example 2: Follow-Up Appointment. S: The patient returned 1 week after routine extraction of
the maxillary right first molar. The patient reported uneventful healing and was “surprised” at how well she felt.
O: No palpation tenderness or suggestion of bleeding or infection. Mucosal color at the extraction site was normal.
A: Healing normally. P: The patient is to be scheduled to discuss prosthetic
replacement of this tooth.
Example 3: Limited Oral Medicine Consultation. S: A 55-year-old male who is an inpatient for reconstruc-
tive knee surgery, due to a skiing accident. The patient has had a recent onset of oral ulceration; he has also complained of gastrointestinal distress. There is no previous history of similar oral ulceration or gastrointestinal disease. The patient is in ASA class I and is not presently taking any medication except for ibuprofen (800 mg) given as an analgesic postsurgically.
O: Classic aphthalike ulcerations of the buccal and labial mucosae and lateral tongue borders. The largest lesion is 0.6 cm in diameter. The total number of lesions is six.
A: Erythema multiforme secondary to ibuprofen therapy. P: Recommend that attending physician discontinue the
use of ibuprofen and substitute acetaminophen, as necessary for analgesia.