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Medical History: Checked, No changes.
Complaints: ……
Extra-oral: TMJ, Lymph nodes, Lips, facial symmetry: NAD
Intra-oral Soft Tissues: Buccal mucosa, palate, gingivae, tongue, floor of mouth: NAD
Intra-oral Hard Tissues Findings: …….
SPECIAL INVESTIGATIONS:
Endofrost:
Tender to Percussion:
RADIOGRAPHS:
Op: ….. Type: Right BW
Reason: To assess bone levels, caries. Grade: A
Findings: …..
Op: …… Type: Left BW
Reason: To assess bone levels, caries. Grade: A
Findings: ……
Op: …… Type: Periapical(PA) of …..
Reason: To assess bone levels, caries, periapical pathology, root morphology, surrounding anatomy
Grade: A
Findings: ……
DIAGNOSIS: …….
DISCUSSION:
Findings discussed. Radiographs discussed as per report above.
Short term and long term treatment options discussed including pros and cons and costs discussed. Benefits, risks and no treatment discussed.
Advised that the treatment provided today might serve as a temporary measure, and the patient may need to seek further treatment after this appointment for definitive work, as discussed.
Treatment plan for this emergency appointment:
1.
Procedure:
....
Next Visit: ...
Dental emergencies require prompt action and accurate note-keeping for effective patient care and follow-up treatment. This guide provides dental practitioners with a detailed emergency dental notes template to ensure that all critical information is captured for each urgent patient visit in 2024.
Comprehensive documentation during a dental emergency is crucial for diagnosis, treatment, legal records, and quality patient care. Notes should encompass the patient's medical history, complaints, clinical findings, radiographs, diagnosis, discussion outcomes, and treatment carried out during the emergency.
The above template offers a structured approach to documenting an emergency dental visit.
Adopting the emergency dental notes template provided will ensure the accurate capture of vital information during emergency visits. Such documentation is indispensable for managing immediate dental care and planning subsequent treatment. In 2024, having a standardized method for documenting emergencies will remain essential for any dental practice committed to quality care.
Watch the demo to see a real example procedure and the notes produced. 📽️
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