Diagnostic Nasal Endoscopy Procedure Note

Note Title: Diagnostic Nasal Endoscopy – Procedure Note

Date/Time: [Date and time of procedure]

Location: [Clinic/office location]

Patient: [Patient name and identifier]

Performing Clinician: [Clinician name and credentials]

Procedure

Procedure performed: Diagnostic nasal endoscopy
Laterality: [unilateral right / unilateral left / bilateral]
Scope type: [rigid / flexible]
Pre-procedure diagnosis: [Brief indication or problem statement]
Post-procedure diagnosis: [Diagnosis based on endoscopic findings] (Include only if different from pre-procedure diagnosis; otherwise omit this line.)

Indication

[Indication paragraph] (1–3 sentences stating the clinical question addressed and why anterior rhinoscopy was insufficient; reference key symptoms with duration, laterality, and severity; include relevant prior evaluation such as imaging findings, failed medical therapy, or abnormal anterior exam. If not documented, insert "Indication not documented.")

Consent

[Consent attestation] (Confirm that [verbal / written] consent was obtained, risks/benefits/alternatives were discussed, patient questions were addressed, and patient agreed to proceed. If not documented, insert "Consent not documented.")

Topical Preparation

[Topical agents used] (Document decongestant and anesthetic agents with route/form and sides applied. If no topical agents were used, state this with reason. Note any adverse reaction; if none, state "no adverse reaction." If not documented, insert "Topical preparation not documented.")

Technique

[Technique description] (Include patient position, scope type, approach with sequential examination of each nasal cavity, key regions examined, whether suctioning was performed for visualization, and any limitations encountered with notation of structures not visualized. If procedure was aborted, document at what point and why. If not documented, insert "Technique not documented.")

Findings

(Document objective findings only for structures actually visualized. For any region not visualized, state "not visualized" with reason. Do not auto-populate normal findings without confirmation from dictation.)

Right Nasal Cavity

• Septum: [Findings / not visualized (reason) / not documented]
• Inferior turbinate and meatus: [Findings / not visualized (reason) / not documented]
• Middle turbinate: [Findings / not visualized (reason) / not documented]
• Middle meatus/ostiomeatal complex: [Findings including patency, polyps, edema, purulence, mucus character, surgical cavity status if post-op / not visualized (reason) / not documented]
• Sphenoethmoid recess: [Findings / not visualized (reason) / not documented]
• Choana/posterior nasal cavity: [Findings / not visualized (reason) / not documented]
• Interpretation: [Brief clinical interpretation if supported by objective findings] (Optional; omit if not applicable.)

Left Nasal Cavity

• Septum: [Findings / not visualized (reason) / not documented]
• Inferior turbinate and meatus: [Findings / not visualized (reason) / not documented]
• Middle turbinate: [Findings / not visualized (reason) / not documented]
• Middle meatus/ostiomeatal complex: [Findings including patency, polyps, edema, purulence, mucus character, surgical cavity status if post-op / not visualized (reason) / not documented]
• Sphenoethmoid recess: [Findings / not visualized (reason) / not documented]
• Choana/posterior nasal cavity: [Findings / not visualized (reason) / not documented]
• Interpretation: [Brief clinical interpretation if supported by objective findings] (Optional; omit if not applicable.)

Nasopharynx

(Include only if nasopharynx was examined; otherwise omit this subsection entirely.)

• Adenoid tissue: [Findings]
• Eustachian tube orifices: [Findings]
• Posterior wall: [Findings]
• Masses/asymmetry: [Present with description / absent]

Endoscopic Severity Score

(Include only if a standardized scoring system is used; otherwise omit this section entirely.)

Scoring system: [Name of system, e.g., Modified Lund-Kennedy]

• Right: [Score]
• Left: [Score]
• Total: [Total score]

Additional Procedures

(Include only if additional procedures were performed; otherwise omit this section. If dictation explicitly states none were performed, include "None.")

• [Procedure type]: [Site and side]; [Method/instrument]

Complications and Tolerance

Complications: [None / epistaxis / vasovagal episode / mucosal trauma / medication reaction / other]
Estimated blood loss: [None / minimal / quantified amount]
Patient tolerance: [Tolerated well / limited by pain / limited by anxiety / limited by bleeding / limited by anatomic obstruction]

Disposition and Follow-up

Disposition: [Stable, discharged home / observed in clinic / other]
Post-procedure counseling: [Return precautions reviewed including bleeding, pain, fever, worsening symptoms]
Plan: [Treatment changes, diagnostics ordered, follow-up timing and purpose]

Signature

[Electronic signature of performing clinician]