Quality of subjective, objective, assessment, and plan-based clinical documentation and its predictive value on treatment planning in excisional biopsy cases: A retrospective study

Objectives: The objectives of the study are to evaluate the completeness and quality of subjective, objective, assessment, and plan (SOAP)-based clinical documentation in excisional biopsy cases and determine its predictive value on treatment planning quality. Materials and Methods: This retrospective analytical study reviewed 156 excisional biopsy records from January 2022 to December 2023. A Documentation Quality Score (DQS) ranging from 0 to 8 was developed, using a 0-2 scale for each SOAP component. Treatment plans were independently assessed by three blinded oral pathologists using a 5-point Likert scale. Statistical analysis: Descriptive statistics were calculated. Pearson’s correlation and linear regression were performed to determine the relationship between DQS and treatment planning quality. Results: The Subjective and Assessment sections were 100% complete, while the Objective section showed the lowest completeness (64.97%) in documenting oral surgery findings. The mean DQS was 7.31 ± 0.51. A moderate positive correlation was observed between DQS and treatment plan quality (r = 0.41, P < 0.001). Regression analysis indicated that Objective documentation was a significant predictor of treatment plan quality (b = 0.33, P = 0.002). Conclusions: High-quality SOAP documentation, especially of objective clinical findings, is positively associated with better treatment planning. Structured clinical records can enhance diagnostic decision-making and improve patient care outcomes.