Endodontic Emergency Visit Note (Pain/Swelling)

Date/Time: [Date and time of encounter]

Patient: [Full name and identifier per policy]

Provider: [Provider name and credentials]

Encounter Type: Endodontic Emergency Visit - Pain/Swelling

Referral Source: [Referring clinician/office and reason] (Only include if applicable)

Chief Complaint

[Primary concern in patient's own words, including laterality and suspected tooth/region if known]

Subjective

[History of present illness] (Brief narrative: onset and time course; pain severity 0-10; pain quality; triggers and relieving factors; patient-perceived localization; swelling details if present including location, progression, intraoral vs extraoral; functional impact; self-care or prior treatment attempted.)

Infection/Airway Screen: [Fever/chills/malaise]; [Trismus severity]; [Voice changes]; [Dysphagia/odynophagia]; [Drooling]; [Tongue or floor of mouth swelling]; [Difficulty breathing]. (Required when swelling present. If pain only without swelling, document brief negative screen. If any element cannot be assessed, state why.)

Relevant Medical History: [Conditions affecting infection risk, anesthesia, or medication choices] (Brief statement or short list.)

Allergies: [Allergen(s) with reaction type, or NKDA]

Current Medications: [Pertinent medications]

Relevant Dental History: [Prior procedures, trauma, restorations, or symptoms involving affected tooth] (Only include if applicable.)

Objective

Vitals: [BP, HR, Temp, RR, SpO2 as relevant] (Include when swelling, systemic symptoms, or medically complex patient. If not obtained, state why.)

Extraoral Exam: [Swelling location/extent; lymphadenopathy; maximal opening if trismus; airway observations]

Intraoral Exam: [Vestibular swelling characteristics; drainage or sinus tract; floor of mouth assessment if swelling present; focused periodontal findings on suspected tooth]

Tooth-Specific Findings: [Tooth #]: [Restoration/caries status; percussion; palpation; mobility; thermal/pulp testing with control comparison; bite test; selective anesthesia if performed]. [Control tooth #]: [Baseline responses]. (Add additional teeth as needed.)

Imaging: [Type, date, key findings relevant to diagnosis] (If not obtained, state why.)

Assessment

[Endodontic diagnosis using AAE standardized terminology] (For each tooth assessed, document BOTH pulpal diagnosis AND apical diagnosis. If uncertain, use "probable" and state why.)

• [Tooth #]: [Pulpal diagnosis] and [Apical diagnosis]. [Key supporting findings]

Infection Severity: [Localized / Systemic involvement present]; [Concern for deep space infection or airway compromise: yes/no]; [Disposition: outpatient management / urgent referral]. (Required when swelling present.)

Plan

[One-sentence summary of intervention performed today and rationale]

Procedure: [Procedure name and indication]; [Consent obtained]; [Anesthesia: type, amount, technique]; [Dental dam isolation]; [Key procedural findings: drainage, canals located, medicament]; [Tooth left open / closed with temporary]. [Patient tolerance and outcome]. (If no procedure performed, state why.)

Medications:

• Analgesic: [Drug, dose, frequency, duration] (Nonopioid first-line unless contraindicated.)
• Antibiotic: [Drug, dose, frequency, duration; indication for prescribing OR rationale if not prescribed; re-evaluation/stop instructions]

Referral: [To whom, reason, urgency; transport instructions if emergent] (Only include if applicable.)

Follow-up: [Timeframe and next steps]

Return Precautions: (Required; document patient verbalized understanding.)

• Worsening swelling or pain
• Fever or chills
• Increasing trismus
• Difficulty swallowing
• Voice changes
• Tongue or floor of mouth swelling
• Difficulty breathing
• Inability to tolerate fluids

(If any element cannot be assessed, document "Not assessed," "Unable to assess due to [reason]," or "Patient declined." Do not leave blanks or infer findings not actually assessed.)