The categorization in the EHR does not match with the actual definitions of the SOAP categories (subjective, objective, assessment, plan).

Subjective section should include anything the patient tells you. This would not only include the CC, HPI, and dental/medical history (as the software shows currently), but should also include the PMHx, PSHx, PFHx, pain & swelling, medications, Rxs, ROS, and implants. The later of these items are all currently misplaced in the objective section but should be in the subjective section.

The objective section should include anything the doctor observes such as clinical and radiographic examinations, tests, and observations. This would include the vital signs, clinical examinations, and radiographic examination findings. Currently the software has misplaced the clinical and radiographic examinations in the assessment category.

Assessment should include the etiology, diagnosis, and differential diagnoses. Currently the software has misplaced the diagnosis into the plan section.

Plan should include the treatment plan and associated prognosis. Currently the plan section also has the diagnosis which should be back in the assessment section along with the etiology.