Free Emergency Palliative Treatment Note Template (D9110)
This palliative treatment note template documents the emergency visit where you relieved pain without definitive treatment: the complaint, focused findings and tests, exactly what you did and where, how the patient responded, and the plan for definitive care. That last part is what separates a defensible D9110 note from "patient seen for pain."
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Emergency visit, palliative treatment (D9110). Chief complaint: "[sharp edge on a lower left tooth cutting my tongue, sensitive to cold since yesterday]". Medical history reviewed; [no changes, no contraindications]. Focused examination: [#19 fractured DL cusp with sharp enamel margins, no pulp exposure; left lateral tongue mildly abraded; no swelling]. Diagnostic tests: Cold [#19 (+) non-lingering, #18 (+) non-lingering, #20 (+) non-lingering]; Percussion [#19 (−), #18 (−), #20 (−)]; Palpation [(−)]. Radiographs: PA #[19]: [no periapical pathology]. Diagnosis: [fractured cusp #19 with reversible pulpitis, normal apical tissues]. Informed consent obtained for palliative treatment. Palliative treatment: [sharp enamel margins #19 smoothed and polished; food impaction removed and area irrigated]. No definitive treatment performed this visit. Patient reports [tongue irritation relieved] before dismissal. [Ibuprofen with or without acetaminophen recommended as needed for discomfort.] Definitive treatment discussed: [crown #19]; risks of delaying treatment reviewed. Next visit: [crown prep #19 within 2 weeks]. Patient advised to return sooner if pain becomes spontaneous or lingering, or if swelling develops.
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When to use this template
Use this palliative treatment note template when a patient presents in pain and you provide hands-on treatment that relieves the symptoms without fixing the cause, and the service has no more specific CDT code. Classic examples: removing a food impaction that is inflaming the papilla, smoothing the sharp edge of a fractured cusp or broken restoration that is cutting the tongue, or relieving a tooth that is tender to bite until definitive care. D9110 is reported per visit, not per tooth, so one line covers all the palliative work done that day. Record every tooth or area you treated anyway.
D9110 is the catch-all, which means it is the wrong code whenever a specific one fits. Pulpal debridement is D3221, incision and drainage of an intraoral abscess is D7510, a protective (sedative) restoration is D2940, a desensitizing medicament is D9910, and a dry socket or other post-surgical complication is D9930. The palliative code also does not include the evaluation or the radiographs. Document the problem-focused exam (D0140) and any periapical film separately; most payers accept D0140 with D9110 on the same visit, though some bundle them. Do not pair D9110 with definitive treatment on the same tooth the same day.
Two prescribing points belong in this note. Per the 2019 ADA guideline, antibiotics are not recommended for pain from irreversible pulpitis or apical periodontitis in immunocompetent adults; they are reserved for signs of systemic involvement such as fever or malaise, or a localized abscess when definitive care cannot be provided. Per the 2024 ADA acute pain guideline, an NSAID with or without acetaminophen is first-line. A prescription alone, without hands-on treatment, is not palliative treatment. Close the note with the definitive treatment discussed and the return-sooner precautions: palliative care is by definition not curative, and the note should show the patient was told so.
Step by step: how to document this emergency palliative treatment
- 1
Capture the complaint
Record the chief complaint in the patient's words with onset and duration, and review the medical history.
- 2
Examine and test
Document the focused exam of the painful tooth or area and per-tooth test results (cold, percussion, palpation, bite), including adjacent teeth as controls.
- 3
Image
Take and read a periapical radiograph of the symptomatic area; it is reported separately from D9110.
- 4
Diagnose
State a working diagnosis, using the pulpal plus periapical pair for tooth pain.
- 5
Relieve the pain
Perform the palliative service and record exactly what was done and where. If the service has its own CDT code, report that code instead.
- 6
Confirm relief and plan definitive care
Note the patient's response, analgesic advice, the definitive treatment discussed, the next appointment, and the return-sooner precautions.
Tips for using this template
- check_circleName the palliative service and the site: "sharp DL margins #19 smoothed" documents hands-on treatment, while "palliative tx given" documents nothing.
- check_circleCheck for a specific code first. Pulpal debridement (D3221), I&D (D7510), protective restoration (D2940), desensitizing medicament (D9910), and post-surgical complications (D9930) all have their own codes; D9110 is for relief that does not.
- check_circleD9110 is per visit, not per tooth. One line covers all palliative work that day, but the note should still list each tooth or area treated.
- check_circleThe evaluation and radiographs are separate services. Document the limited exam (D0140) and the PA on their own; some payers bundle D0140 with D9110, so verify the plan.
- check_circleA prescription by itself is not palliative treatment. If all you did was examine and prescribe, the visit is the exam plus the prescription.
- check_circlePer the 2019 ADA guideline, antibiotics are not indicated for toothache from irreversible pulpitis or apical periodontitis in immunocompetent adults without systemic signs. Document your reasoning whether you prescribe or not.
- check_circleRecord the patient's response before dismissal ("pain relieved", "irritation resolved"). It shows the treatment did what the code says it did.
- check_circleAlways end with the definitive plan and the return-sooner conditions. An emergency note that just stops is the gap that matters if the tooth flares over the weekend.
Standards & references
- ADA Code on Dental Procedures (CDT): D9110 (palliative treatment of dental pain, per visit) and the specific codes that take precedence over it (D3221, D7510, D2940, D9910, D9930).
- ADA Oral Health Topics: Antibiotic Stewardship: Summary of the 2019 ADA guideline: definitive or palliative dental treatment, not antibiotics, for most pulpal and periapical pain in immunocompetent adults.
- ADA Oral Health Topics: Oral Analgesics for Acute Dental Pain: NSAIDs, alone or with acetaminophen, as first-line therapy for acute dental pain, per the 2024 ADA-endorsed guideline.
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