General note

0140, 0220, 7010, ext...


Reviewed HHx (Indicate any existing conditions/positive health findings i.e.: allergies, HTN, Diabetes, Infectious diseases, Medications) or Patient denies history of asthma, allergies, CVD, DM, ID, seizure disorders, psychiatric disorders, surgeries, hospitalizations, medications.

BP xx/xx mmHg LASit/RASit

Radiographs: 1 PA/PAN/BW

Tooth #xx


Discussed with patient all treatment options, patient choose extraction treatment. Patient referred to O.S. for extraction.

O.S. appointment: date and time

Rx: none/prescription

Patient was advised about the need and importance of comprehensive dental care.

Chief Complaint

xx yo AA/CAU/Asian/Hisp M/F presents to emergency clinic.

CC: "In patient’s own words"

HPI: Expand on the CC

Onset: Patient states pain began a week ago

Location: Patient states upper/lower right/left front/back tooth/teeth

Duration: Patient states pain is intermittent/spontaneous/constant

Severity: Patient states xx on a scale of 1-10 with 10 being the worst pain

Character: Patient states radiating/throbbing/dull pain on entire right/left side of the face or localized pain.

Patient states this keeps him/her awake at night

Aggravating factors: Patient states heat, cold, air, palpation, mastication

Relieving factors: Patient states meds/home remedies will help relieve the pain

Associated factors: fever/swelling/exudates)

Clinical Findings

Intraoral exam affected area(s):


Percussion: (+-)

Palpation: (+-)

Cold: (+-) NL/L

Mobility: None or Miller Class I/II/III

Probing depths: WNL

Furcation involvement: None or Glickman Class I/II/III/IV

Options and Proposed Emergency Treatment

Discussed with patient all tx options including:

1. Pain management

2. Extraction of #xx

3. GPD today followed by RCT, CL, PFM crown

Patient chooses option #2. Patient referred to O.S. for extraction.