What should be included in a sample ear wax removal and irrigation procedure note template?

Ear Wax Removal and Irrigation Procedure Note Template

A comprehensive ear wax removal and irrigation procedure note should document the indication, technique, findings, and outcomes to ensure proper medical documentation and patient safety. 1

Patient Information Section

• Patient name, DOB, MRN 1
• Date and time of procedure 1
• Provider name and credentials 1

Indication/History

• Presenting symptoms (hearing problems, fullness, itching, pain, discharge, odor, cough) 1
• Duration of symptoms 1
• Previous ear wax removal attempts 1
• Relevant medical history (ear surgeries, perforated tympanic membrane, ear infections) 1

Pre-Procedure Assessment

• Otoscopic examination findings (amount and type of cerumen impaction) 1
• Confirmation of cerumen impaction diagnosis based on:
  • Accumulation of cerumen causing symptoms 1
  • Cerumen preventing needed assessment of the ear 1
  • Both of the above 1
• Contraindications assessed (history of ear surgery, perforated tympanic membrane, ear infection, ear pain) 1
• Informed consent obtained after explaining procedure, risks, and benefits 1

Procedure Details

• Method(s) used (select all that apply): 1
  • Cerumenolytic agents (specify type and duration of application) 1, 2
  • Irrigation (specify solution type and temperature) 1
  • Manual removal (specify instruments used - curette, forceps, suction) 1
• Technique description: 1
  • For irrigation: water temperature, pressure settings, direction of water stream 1, 3
  • For manual removal: visualization method, instruments used 1
• Patient positioning during procedure 1, 4
• Patient tolerance of procedure 1

Findings

• Amount and consistency of cerumen removed 1
• Visualization of tympanic membrane (complete, partial, unable) 1
• Tympanic membrane appearance if visualized (intact, landmarks visible, color) 1
• External auditory canal condition (erythema, edema, abrasions) 1, 3

Post-Procedure

• Complications (if any): pain, dizziness, vertigo, canal trauma, tympanic membrane perforation 1, 5
• Post-procedure instructions provided to patient: 1
  • Avoid inserting objects into ear canal 1
  • When to seek medical attention (pain, discharge, hearing loss) 1
  • Preventive measures if applicable 1
• Follow-up recommendations 1

Assessment and Plan

• Resolution of symptoms (complete, partial, none) 1
• Need for additional interventions 1
• Recommendations for prevention of recurrence 1
• Follow-up plan 1

Provider Information

• Signature 1
• Date and time 1

Important Considerations and Cautions

• Document contraindications to ear irrigation including history of tympanic membrane perforation, ear surgery, or active infection 1
• Avoid recommending cotton-tipped swabs for home use as they can push cerumen deeper and cause trauma 1
• Document patient education regarding ear candling/coning being ineffective and potentially harmful 1
• Note any pre-existing conditions that may increase risk of complications 1, 5
• Document that patients were advised that cerumen is a normal protective substance and only requires removal when causing symptoms or preventing examination 1