Record medical safety first, then an injury baseline, treatment, instructions, and disposition.
- History: medical conditions, medications/allergies, tetanus history, mechanism, timing, witnesses, and prior care.
- Safety: head/neck symptoms, mental status, respiratory symptoms, and other bodily injuries.
- Findings: extraoral/intraoral examination, soft tissues, occlusion, tooth-by-tooth findings, and indicated imaging/interpretation.
- Plan: diagnosis, treatment performed, counseling, follow-up, and referrals so the next clinician can continue care.