When to use this emergency exam template
Use it for limited, problem-focused evaluations (D0140): walk-ins, same-day toothaches, broken teeth, swelling, and trauma. Emergency notes are often written in a hurry between scheduled patients, and they are also the notes most likely to be reviewed later. A structured template makes it hard to skip the tests and the diagnosis.
What an emergency note needs
- The chief complaint in the patient's words, with onset, pain level, and character.
- Objective tests: cold, percussion, palpation, bite test, and radiographs, including normal results.
- A pulpal and apical diagnosis, not just "toothache."
- What you did today and what you prescribed.
- The options presented and the patient's decision, especially if they declined definitive care.
- Return precautions, such as spreading swelling, fever, or trouble swallowing.
Example emergency note
Patient seen for a limited evaluation, problem focused (D0140). Chief complaint: toothache, lower left #19. Onset 1–3 days ago. Pain 7–10/10, throbbing, lingering after cold, wakes patient at night. Cold test: lingering response. Percussion: tender. Periapical taken, showing caries approaching the pulp and a widened PDL space. Diagnosis: symptomatic irreversible pulpitis with symptomatic apical periodontitis. Treatment today: pulpal debridement. Options presented: root canal therapy or extraction. Patient elected root canal therapy, scheduled. Instructions: take medication as directed, call if symptoms worsen.