Home > Topics > Record-keeping > Records Required > Emergency Patient Assessment (unscheduled visit)

Emergency Patient Assessment (unscheduled visit)

An emergency assessment is likely to be carried out because of pain or trauma suffered by the patient. Emergency care can be provided to registered and non-registered patients. In both cases, comprehensive records must be kept. For information on how to categorise ’emergency’ patients refer to the SDCEP guidance Emergency Dental Care.

Record a medical history, which is particularly important in the case of trauma.

If the patient is in pain and the emergency appointment is their first visit, focus on resolution of the presenting complaint, and record what treatment has been carried out.

Conduct an examination as required, and record all details of the examination.

Record a diagnosis together with details of any tests carried out.

Agree treatment with the patient and record details in writing.