Incision & Drainage Procedure Note (Odontogenic Infection)

Date/Time: [date and time of procedure]

Location/Setting: [clinic / ED / OR / bedside]

Operator(s): [operator name(s) with credentials and role(s)]

Procedure Performed: I&D odontogenic abscess; approach: [intraoral / extraoral / both]; anatomic space(s): [space(s) involved]; laterality: [left / right / bilateral]; drain placed: [yes / no]; suspected source tooth: [tooth number / unknown]

Pre-Procedure Diagnosis: [diagnosis prior to procedure]

Post-Procedure Diagnosis: [diagnosis after procedure]

Indication

[1–3 sentence rationale for drainage, including key clinical features supporting need such as fluctuance, progressive swelling, trismus, fever, or imaging findings]

Pre-Procedure Assessment

• Spaces involved: [space(s) and laterality] ([clinically suspected / imaging-confirmed])
• Infection severity markers: [fever / tachycardia / rapid progression / floor-of-mouth elevation / none]
• Trismus: [present / absent]; interincisal distance: [mm / not measured]
• Airway screening: stridor [present / absent]; dyspnea [present / absent]; drooling [present / absent]; dysphagia [present / absent]; voice change [present / absent]
• Relevant allergies: [antibiotics / local anesthetics / other / NKDA]
• Anticoagulation/bleeding disorder: [agent(s) or condition(s) / none]
• Immunocompromised status: [condition or therapy / none]
• Prior antibiotics this episode: [agent(s), duration / none]
• Imaging reviewed: [modality and key findings guiding approach / none obtained]
• Airway escalation plan: [plan if concern present / not indicated]

Consent

[REQUIRED: Document consent obtained from patient / legal representative / emergency exception. Include: procedure explained in lay terms; risks discussed including bleeding, pain, infection spread, nerve or duct injury, scarring if extraoral, need for repeat drainage or admission/airway intervention, anesthetic risks; benefits and alternatives discussed; questions answered; agreement to proceed. If emergency exception, document justification.]

Time-Out

[REQUIRED: Time-out performed — correct patient, correct procedure, correct site/side/space(s), allergies verified, imaging available, equipment ready. If not performed, document reason.]

Anesthesia

• Local anesthetic: [agent and concentration] — [volume or dose]; technique: [infiltration / nerve block: IAN / mental / PSA / other]; site(s): [injection location(s)]; tolerance: [tolerated well / adverse reaction details]
• Sedation: [not used / used — provider and reference to sedation record]

Procedure

• Preparation: [patient position]; prep: [antiseptic agent]; suction ready
• Incision: [precise location using anatomic landmarks, intraoral vs extraoral, laterality]
• Dissection: [blunt dissection performed; loculations addressed; space(s) entered and confirmed]
• Drainage: [estimated amount in mL]; character: [purulent / serosanguinous / other]; odor: [present / absent]
• Culture: [obtained — specimen type and site, sent for aerobic/anaerobic / not obtained — rationale]
• Irrigation: [irrigant type]; volume: [mL]; endpoint: [until return cleared]
• Drain: [placed / not placed]; (if placed: type [Penrose / vessel loop / other]; number; course from incision into [space(s)]; secured with [suture / tape])
• Wound: [left open / partially closed]; hemostasis: [method]; EBL: [mL]
• Complications: [none / description]
• Patient tolerance: [tolerated well / details]

Findings

[1–3 line summary of confirmed space(s) drained, key anatomic observations, unexpected findings. If no frank purulence, document explicitly with interpretation.]

Post-Procedure Status

[Immediate condition]; disposition: [home / admission / transfer]; [consults or hand-offs if applicable]

Medications and Follow-Up

• Antibiotics: [prescribed: drug, dose, frequency, duration / not prescribed — rationale] (Note plan to adjust based on culture results if obtained.)
• Analgesia: [medication plan]
• Drain care: [keep in place, expected drainage, avoid dislodgement, oral hygiene instructions]
• Follow-up: [timing for reassessment and drain removal; responsible provider; who follows culture results]
• Source control: [extraction / root canal — performed today / scheduled with provider]
• Return precautions discussed: worsening swelling, fever/chills, new or worsening trismus, dysphagia, drooling, voice change, breathing difficulty, inability to take oral intake, uncontrolled bleeding