DEFINITION OF DIAGNOSES FOR EAR CAMP OUT-PATIENT FORMS.

medicalrecords

Patient diagnoses and treatments are all recorded and entered to a database questionnaire.
In order to standardise the statistical analysis of diagnoses on different camps and by different doctors the following guidance is prepared.
These notes are to be read in advance to aid the recording of diagnoses on the patient record sheets.
These details are transferred to a WHO epidemiology programme (EPI INFO) adapted for us as an ear camp database. Accurate and complete recording is essential.
The person checking the records at the door and/or putting the details into the database has been told they
must return the papers to the examining doctor whenever a diagnosis is not correctly recorded!

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General notes

Main diagnosis Indicate in this section only the principal/ most significant diagnosis for each ear.

Side: / L / Bilateral (R+L) Record one of these options beside each of your diagnoses. (Do not just tick a diagnosis)

Sending for audiometry or ear syringing Before sending patient away for these, wherever possible record the presumed diagnosis, and change it later if necessary. (Some patients get lost once they go away). (Ensure that carbon copy is correctly positioned under main copy)

Double diagnoses If there really is more than one important diagnosis per ear, then insert secondary diagnosis under ‘other’.


Specific diagnoses

CSOM (Chronic Suppurative Otitis Media) sub-classified as TT, AA, or Unclassified.

AA (Attico-Antral CSOM) (Squamous)
This means attic or postero-superior marginal disease. It includes definite cholesteatoma, wet retraction pockets, pockets with granular margins and pockets that intermittently discharge.

TT (Tubo-Tympanic CSOM) (Mucosal)
This means perforations of the drum of any size, wet or dry, active or inactive. It includes pinhole perforations in small children when the history suggests chronic discharge (commonly seen on camps). It does not include acute otitis media with short history and obvious recent onset.

Unclassified
This should not often be used. It is usually possible to decide between the above two diagnoses, perhaps after mopping and syringing the ear.

(
Note for computer database, when these details are transferred to the computer the codes are:
A = unilateral AA CSOM, AA = bilateral AA CSOM,
T = unilateral TT CSOM, TT = bilateral TT CSOM,
AT = TT CSOM in one ear and AA CSOM in other ear,
UN = unclassifiable CSOM)

AOM (Acute Otitis Media)
Either current AOM or a history suggesting recent or recurrent episodes of AOM

O.E (Otitis Externa)
This includes the common complaint of chronically itching ear, often with no physical signs on examination. It also includes acute or chronic, diffuse or furuncular, bacterial or fungal O.E.

Tinnitus
Only recorded when this is the main complaint in that ear.

Glue (Middle ear effusion)
Fluid of thick or watery consistency, short or long duration in middle ear.

Myringitis
Granulations on the tympanic membrane without any apparent perforation or pocket. AA CSOM. When perforations or pockets are apparent then the main diagnosis will be TT or AA

Wax
Only use this when it is the main diagnosis for that ear. Sometimes it appears to be the main problem and has to be revised after syringing/cleaning the ear.

Dry/Atelectatic
This means either a dry pocket of part of the drum or total atelectasis with retraction of all the tympanic membrane. The pocket should be dry, with no granulations, containing no keratin/cholesteatoma and having no history of recurrent discharge (if there is discharge the ear should be classed as AA CSOM). The pocket or erosion may be of the pars flaccida or pars tensa.

CHL
Only to be used when the drum is intact and the main problem is conductive hearing loss. Please record in all cases whether your presumed diagnosis is otosclerosis Yes or No. The computer database requires an answer to this question.

SNHL

Mild/Moderate/Severe/Profound
Record when sensori-neural hearing loss is the main problem in that ear. The database requires an answer to the question: mild, moderate, severe or profound loss, for each ear.

Dumb
If the answer is profound it requires an answer to the question: is the patient dumb (unable to speak) yes/no.

Other
Can put any details here for any other condition. Certain ‘Others’ occur often enough to make it easier if you put them in identical word form so that the computer will aggregate them. E.g. Meatal atresia, impetigo, rhinitis, goitre, foreign body in ear, pre-auricular sinus, otalgia (when despite examination of referral sites no cause is apparent), dental etc.

In the case of ears which have had surgery, especially on our own camps, please put some essential details on the card such as when and where done, what operation appears to have been done and the result, such as wet/dry, hearing level. Send the patient for audio and ensure they annotate it as post-op. Fill out a separate post-op record sheet, available in OPD. If the patient has their operation papers with them make a note of the op date and the camp place and patient number. (the number and place are essential). Only with as much info as possible can we trace them and assess our results. Please record the details including patient number, not just on the patient record but also separately to help us to search out their records.


Other information on the patient record

- Medicines: please record the information such as drops in the section provided.
- Audios: write the request and say if it is only needed if e.g. the patient agrees to surgery
- Syringing: if the wax looks hard it may be best to prescribe wax drops for 2-3 days then return for syringing. If there is much discharge it is often quicker to ask for gentle syringing before trying to mop the ear.
- Hearing aid: write the request here
- Operation: write the proposed operation and side (which may depend on a subsequent audio)
- Write the level of priority e.g. low, medium, high, very high
- Even when we know that we cannot operate on this patient due to lack of time, still write the planned treatment so that if they ask other doctors it is clear what is needed and they may be able to obtain help elsewhere.

2004 MCFS


Patient OPD paper 2012

Dental and General Medical Record Sheet - 2012