MEDICAL RECORDS
All patients have a paper record file that is printed with sections for diagnosis, investigations, audiogram, and treatment including medicines, hearing aid, operation and priority. There is a carbon copy paper kept beneath the main copy. The patient retains one copy for future use (as they also do with all operation records) and one copy is kept in our medical records files. In some areas we are now moving towards electronic records, paper copies will remain available for patients. We enter the demographics and treatments into a database for audit purposes.
Patients requiring medicines are passed to pharmacy. We carry some information leaflets that can be ‘prescribed’, such as how to keep the ear dry, how to ‘pop’ the ear (Valsalva manouevre).
OPD Record Sheet
We are constantly improving and modifying our recording systems. The following is the front page of a recent out patient record. We aim to give a clear diagnosis or differential diagnosis and treatment plan or treatment options for all patients
Patients requiring medicines are passed to pharmacy. We carry some information leaflets that can be ‘prescribed’, such as how to keep the ear dry, how to ‘pop’ the ear (Valsalva manouevre).
OPD Record Sheet
We are constantly improving and modifying our recording systems. The following is the front page of a recent out patient record. We aim to give a clear diagnosis or differential diagnosis and treatment plan or treatment options for all patients
General notes for record keeping
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)
Before sending patient for audiometry or ear syringing,; wherever possible record the presumed diagnosis, and change it later if necessary.
Double diagnoses If there is more than one important diagnosis per ear, then insert secondary diagnosis under ‘other’.
Specific diagnoses
We aim for standardisation of diagnoses, between different doctors and staff, to enable better audit.
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 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, micro-suction or syringing the ear.
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 as principle diagnosis 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. When perforations or pockets are apparent then the main diagnosis will be TT or AA CSOM
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.
Conductive hearing Loss (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) as our computer database requires an answer to this question.
Sensorineural hearing loss (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 hearing loss is recorded as profound, then the database requires an answer to the question: is the patient dumb (unable to speak) yes/no.
Other
Please put 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, or at the Ear Centre please record some essential details on the card such as when and where the surgery was done, what operation appears to have been done and the result, such as wet or dry and hearing level. Send the patient for audio and ensure they annotate it as post-op. Please fill out a separate post-op record sheet, available in OPD. If the patient has their operation papers with them it is essential to note the date of the op, the place that operation was done and the patient number.
Other information on the patient record
- Medicines: please record in the section provided.
- Audios: write the requested tests such as PTA, Tympanometry, Stapedial reflexes, ABR.
- 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 and microsuction not available, it is often quicker to ask for gentle syringing before trying to dry mop the ear.
- Hearing aid: write the request here
- Operation: write the proposed operation and side (which may depend on a subsequent audio), record any discussion with patient such as the principle goals of the surgery, significant risks in this case, or limitations on what can be achieved that have been explained.
- Write the level of priority for surgery e.g. low, medium, high, very high
- Arrange for consent and media release form to be completed
- Complete pre-operative assessment forms
Media Release and Consent Form
Patients sign a consent form (download here) detailing the procedure and risks before surgery.
We are reliant on donors to enable a high level of service, training, outreach, and equipment. We request that patients and carers agree to the occasional use of stories and photographs in teaching and in fund raising. They have an opportunity to refuse this during the consent process.
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)
Before sending patient for audiometry or ear syringing,; wherever possible record the presumed diagnosis, and change it later if necessary.
Double diagnoses If there is more than one important diagnosis per ear, then insert secondary diagnosis under ‘other’.
Specific diagnoses
We aim for standardisation of diagnoses, between different doctors and staff, to enable better audit.
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 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, micro-suction or syringing the ear.
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 as principle diagnosis 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. When perforations or pockets are apparent then the main diagnosis will be TT or AA CSOM
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.
Conductive hearing Loss (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) as our computer database requires an answer to this question.
Sensorineural hearing loss (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 hearing loss is recorded as profound, then the database requires an answer to the question: is the patient dumb (unable to speak) yes/no.
Other
Please put 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, or at the Ear Centre please record some essential details on the card such as when and where the surgery was done, what operation appears to have been done and the result, such as wet or dry and hearing level. Send the patient for audio and ensure they annotate it as post-op. Please fill out a separate post-op record sheet, available in OPD. If the patient has their operation papers with them it is essential to note the date of the op, the place that operation was done and the patient number.
Other information on the patient record
- Medicines: please record in the section provided.
- Audios: write the requested tests such as PTA, Tympanometry, Stapedial reflexes, ABR.
- 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 and microsuction not available, it is often quicker to ask for gentle syringing before trying to dry mop the ear.
- Hearing aid: write the request here
- Operation: write the proposed operation and side (which may depend on a subsequent audio), record any discussion with patient such as the principle goals of the surgery, significant risks in this case, or limitations on what can be achieved that have been explained.
- Write the level of priority for surgery e.g. low, medium, high, very high
- Arrange for consent and media release form to be completed
- Complete pre-operative assessment forms
Media Release and Consent Form
Patients sign a consent form (download here) detailing the procedure and risks before surgery.
We are reliant on donors to enable a high level of service, training, outreach, and equipment. We request that patients and carers agree to the occasional use of stories and photographs in teaching and in fund raising. They have an opportunity to refuse this during the consent process.