Documentation of Dried Blood in the Nose
When documenting dried blood in the nose, record the presence of dried blood as a clinical finding, document any associated risk factors for epistaxis, and note whether active bleeding is present or has resolved. 1
Essential Documentation Elements
Primary Clinical Findings
- Document the specific location and appearance of dried blood (anterior nares, nasal cavity, or nasopharynx) and whether it represents resolved bleeding or requires intervention 2
- Note whether active bleeding is currently present or if only dried blood/crusting is visible 1
- Record findings from anterior rhinoscopy after any clot removal to identify the bleeding site 1, 3
Mandatory Risk Factor Documentation
The American Academy of Otolaryngology-Head and Neck Surgery requires documenting factors that increase bleeding frequency or severity 1:
- Personal or family history of bleeding disorders 1
- Anticoagulant or antiplatelet medication use (this is critical for medicolegal purposes) 1
- Intranasal drug use 1
- Prior nasal or sinus surgery 1
- Nasal trauma 1
- Nasal cannula oxygen or CPAP use 1
- Chronic kidney or liver disease 1
- Hypertension 1
- Cardiopulmonary disease 1
- Anemia 1
Treatment and Intervention Documentation
- Document any interventions performed, including topical vasoconstrictors, nasal cautery, or moisturizing agents applied 3
- If nasal packing was placed, document the type of packing, timing and plan for removal, and patient education provided 1
- Record whether the bleeding site was identified and treated 3
Clinical Context and Management
When Dried Blood Indicates Recent Resolved Bleeding
- Educate patients about preventive measures including nasal saline irrigation 3-4 times daily and petroleum jelly application 2-3 times daily to prevent recurrence 4
- Instruct patients to use a humidifier at bedside 2, 4
- Advise patients to avoid nose blowing, strenuous activity, and placing cotton or tissues in the nose for at least one week 2
Follow-up Documentation Requirements
The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting outcomes within 30 days or documenting transition of care for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 1. This is important because recurrence rates vary from <10% for surgical interventions to 50% for nasal packing 2.
Critical Documentation Pitfalls to Avoid
- Do not document dried blood without assessing for active bleeding, as this may represent ongoing epistaxis requiring immediate intervention 1
- Always document anticoagulation status, as failure to do so creates medicolegal risk and affects treatment decisions 1
- Document whether the patient was educated about warning signs requiring prompt reassessment 1
Special Population Considerations
- For patients with recurrent bilateral dried blood or family history of recurrent nosebleeds, document assessment for hereditary hemorrhagic telangiectasia (HHT) by examining for nasal and oral mucosal telangiectasias 1
- For patients on anticoagulation, document that the prescribing clinician was contacted, as these medications treat serious medical conditions and should not be stopped without consultation 2, 1