Headings
Chief complaint · Pain history · Medical history · Examination · Tests · Radiographs · Diagnosis · Treatment given · Plan
When to use it
Use this for an unscheduled visit for pain, swelling or trauma. It follows the diagnostic path from pain history to tests to radiographs, so your diagnosis is clearly supported. It also records what you did today to relieve pain and what definitive care is still owed.
Example
Fictional example
Chief complaint
Throbbing pain lower left. Woke patient last night.
Pain history
3 days. Spontaneous. Lingers after cold. Ibuprofen helps partly.
Medical history
Penicillin allergy, rash. No other conditions.
Examination
Deep distal caries #20. No swelling or sinus tract.
Tests
Cold on #20 lingers 20 seconds. Mild percussion tenderness. Adjacent teeth normal.
Radiographs
Periapical: caries near pulp, widened ligament space.
Diagnosis
Symptomatic irreversible pulpitis with symptomatic apical periodontitis #20.
Treatment given
Inferior alveolar block, 1 carpule 2% lidocaine with 1:100,000 epinephrine, 36 mg. Pulpectomy, calcium hydroxide, temporary filling.
Plan
Finish root canal in 2 weeks. Ibuprofen and acetaminophen for pain. No antibiotic indicated.