We developed an emergency care assessment form to help organize the doctors and staff for effective emergency case management (Figure). We incorporated the well-known SOAP format because it is an excellent assessment tool—recognized universally and easily learned. SOAP is defined as follows:

View larger version (31K): [in this window] [in a new window]   Figure. An assessment form organized according to the SOAP principle—subjective, objective, appraisal, plan—can aid in dealing with dental emergencies.

– subjective findings—the patient’s explanation of his or her condition;

– objective findings—the clinical findings of the doctor’s examination;

– appraisal—the doctor’s diagnosis based on the subjective and objective findings;

– plan—how the necessary procedures will be completed to facilitate case management and resolution.

An excellent review of the theory of, method of and justification for SOAP record documentation was provided by Weed,¹ who initiated the subsequent development of the documentation method.

Our emergency care assessment worksheet allows doctors or staff members to circle or highlight quickly the basic findings of the emergency case. The doctors and staff members write in additional information as applicable. (The form is not intended to be all-inclusive.)

Dentists can use the assessment form for internal gathering and organizing of information. After the disposition of the case, when time allows, the assistant can review the form and record the pertinent details in the permanent record. The dentist then can survey the chart entry for accuracy. The form generally is discarded at that point but may be kept, if appropriate, in the progress notes area.

We have revised our emergency assessment form many times over the years. We print copies of our master document and stock our operatories with them as necessary. The emergency patient assessment form helps us standardize and organize our emergency case management. The results are consistent, detailed chart documentation and, most importantly, improved care for patients with dental emergencies.

DO YOU HAVE A TIP TO SHARE
Do you have a time- or work-saving clinical technique to share with your colleagues? Submit it to JADA’s Clinical Directions department. A Clinical Directions item should be a maximum of two double-spaced typed pages and should include no more than one figure or illustration. Submit five copies of your manuscript and of each illustration to Clinical Directions, The Journal of the American Dental Association, Editorial Office, University of Pennsylvania, School of Dental Medicine, The Robert Schattner Center, 240 S. 40th St., Philadelphia, Pa. 19104-6030.