Problem-Focused Dental Visit Note (Urgent/Emergency)

Patient name: [Patient full name]

DOB: [Date of birth]

Date/Time: [Encounter date and time]

Location: [Clinic/ED name or setting]

Provider: [Clinician name, credentials]

Reason for visit: [pain / swelling / trauma / broken tooth or restoration / other]

Subjective

Chief Complaint: "[Patient's own words describing the problem]"

History of Present Illness: [Narrative including onset, location with tooth number and notation system, severity, quality, provoking/relieving factors, and functional impact. For infection: fever, trismus, dysphagia, dyspnea. For trauma: mechanism and time since injury. Note any self-treatment attempted.]

Relevant History: [Pertinent allergies, medications affecting dental care, and key medical conditions] (If history cannot be obtained, state reason.)

Objective

Vitals/General: [Relevant vitals and general appearance] (Capture when swelling, systemic symptoms, or trauma present. If not assessed, state reason.)

Extraoral: [Facial swelling, lymphadenopathy, trismus with interincisal opening, TMJ findings as relevant]

Intraoral: [Soft tissue findings, gingival condition, sinus tract presence and location]

Tooth Exam: [Tooth number(s) with notation system, percussion, palpation, mobility, visible pathology, fracture/displacement findings] (For trauma, note baseline sensibility test results recognizing early tests may be unreliable.)

Diagnostic Tests: [Pulp/periapical testing performed? If no, state reason.] (Include table only if testing was performed.)

Test type	Tooth tested	Control tooth	Result
[Test type]	[Tooth number]	[Control tooth number]	[Response and interpretation]

Imaging: [Type, indication, and interpretation including periapical findings, fracture suspicion, or bone loss] (If not obtained, state reason.)

Assessment

1. [Problem]: [Working diagnosis with brief supporting findings] (For endodontic issues, include pulpal and periradicular diagnoses when determinable.)

Differential: [Plausible alternatives]

Severity flags: [Systemic involvement, airway concerns, significant trismus] (Include only if present.)

Plan

• Treatment Rendered: [Procedure(s) with tooth number and key details] (If no treatment rendered, state rationale.)
• Anesthesia: [Agent, dose, site, technique] (Include only if local anesthetic or nitrous administered.)
• Prescriptions: [Medication, dose, quantity, directions]
  • (For antibiotics, document rationale: systemic involvement / definitive treatment unavailable / high-risk patient.)
  • (For opioids: note PDMP check, limited quantity rationale, and counseling provided.)
• Referrals: [Specialty, urgency, information sent] (Include only if applicable.)
• Patient Instructions: [Expected course, self-care guidance, return precautions: worsening swelling, fever, difficulty swallowing or breathing, uncontrolled bleeding]
• Disposition: [Condition at discharge, follow-up timeframe, appointment scheduled: yes / no]

(If any section has no applicable content, include status note such as "Not assessed" or "Unable to obtain" rather than omitting.)