Most of this information comes form the green sheet in most of the emergency bays.
Assuming you're doing an OS consult, here's the procedure for that:
0140, 0220, 7010, etc…
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 _/_ mmHg LASit/RASit P ___ bpm S&R
Radiographs: 1 PA/PAN/BW
Tooth #xx Dx:
Discussed with patient all treatment options, patient choose extraction treatment. Patient referred to O.S. for extraction.
O.S. appointment: date and time
Patient was advised about the need and importance of comprehensive dental care.