Dr.+Closmann+SOAP+Note+Example

S: Patient expresses that she had pus in her mouth yesterday that had a bitter taste. She came in to make sure nothing was wrong. O: BP: 128/78, Pulse: 85BPM, 97% O2. Extraction sites on #14 and 15 have granulation tissue forming. scant pus visible, no other s/s infection, no s/s sinus perf/damage noted, TTP (tender to palpation) A: likely low grade infection vs. delayed healing/osteitis P: Prescribed 300mg of Clindamycin qid for 7days due to pus formation. Patient was asked to come in next Friday for further follow up. OHI, encouraged saline rinses 3-4x qday.