Foreign Body Removal Procedure Note (Ear/Nose)

Procedure Information

• Date/Time of Procedure: [Date and time]
• Location/Setting: [ED / urgent care / clinic / OR / other]
• Operator: [Name and credentials]
• Procedure Site(s): [right ear / left ear / both ears / right naris / left naris / both nares]

Indication and Clinical Context

[Brief narrative indication and context] (2–4 sentences summarizing indication for removal; time since insertion/incident if known; relevant symptoms such as pain, hearing change, discharge, bleeding, obstruction, rhinorrhea; and any prior removal attempts by caregivers or clinicians.)

• High-Risk Object Screening: [button battery: yes / no / suspected] · [magnet(s): yes / no / suspected] · [sharp object: yes / no / suspected] · [organic/vegetable matter: yes / no / suspected] · [live insect: yes / no / suspected] · [none identified] (If any high-risk object is present or suspected, document estimated dwell time and urgency considerations below.)
• If high-risk object present/suspected: [Estimated dwell time] · [Urgency considerations, tissue injury noted, escalations initiated] (Omit this line if no high-risk objects identified.)

Pre-Procedure Assessment

(Document each involved site separately. If any structure cannot be assessed, explicitly document the reason.)

Ear

(Include only if ear is involved.)

• Canal condition: [normal / edema / erythema / laceration / bleeding / discharge]
• Foreign body: [Visibility and depth; graspable edge: yes / no / unclear]
• Tympanic membrane: [intact / perforated / unable to assess: (reason)]
• Baseline hearing assessment: [Method and findings / unable to perform: (reason)]

Nose

(Include only if nose is involved.)

• Foreign body: [Visibility and location: anterior / posterior; relation to septum/turbinates]
• Mucosal condition: [normal / edema / erythema / ulceration / necrosis]
• Active bleeding: [none / minimal / moderate / severe]
• Aspiration concern: [yes / no] (If yes, state rationale.)

Consent

• Consent type: [verbal / written / both / emergency exception]
• Consent provided by: [patient / parent or guardian / other]
• [Risks, benefits, and alternatives discussed with opportunity for questions] (Risks include bleeding, pain, mucosal/canal laceration, infection, TM injury or hearing change for ear, posterior displacement or aspiration for nose, and potential need for sedation or ENT/OR removal.)
• (If consent not obtained due to emergency circumstances, document the clinical basis.)

Time-Out

• Time-out performed: [yes / no: (reason)]
• [Two patient identifiers confirmed]
• [Correct procedure confirmed]
• [Correct site and laterality confirmed]
• [Allergies reviewed]
• [Required equipment available]

Anesthesia and Analgesia

• Topical/local anesthesia: [none / agent, concentration, route, site]
• Nasal vasoconstrictor: [none / agent and concentration] (Include only for nasal procedures.)
• Analgesia: [none / medication, dose, route, time]
• Procedural sedation: [none / brief summary of medications with doses, routes, times; monitoring; adverse events] (Or reference separate sedation record by name/location.)

Procedure Details

[Narrative description of the procedure] (Describe patient positioning and immobilization if used; visualization tools such as otoscope, nasal speculum, headlamp, or endoscope; and stepwise technique. For live insects in the ear, document immobilization prior to extraction. For button batteries or magnets, emphasize urgency and document any visible tissue injury.)

• Techniques used: [irrigation / suction / forceps / hook / curette / loop / balloon catheter / positive-pressure / adhesive / magnet-assisted / other] (List in sequence of attempts.)
• Instruments: [Specific instruments utilized]
• Number of attempts: [Count]
• Bleeding during procedure: [none / minimal / moderate / severe] · [Hemostasis method if applicable]

Foreign Body Description

• Number removed: [Count]
• Material/type: [metal / plastic / organic / battery / magnet / insect / bead / other]
• Size and shape: [Approximate size; round and smooth / irregular / sharp edges]
• Integrity: [intact / fragmented / unknown until removal]

Removal Status

• Status: [complete / partial / unsuccessful / aborted]
• (If incomplete, unsuccessful, or aborted, document the reason and next steps including escalation plans such as ENT consult, imaging, sedation, or OR.)

Post-Removal Assessment

(Required even if findings are normal. If full exam not possible, document what was assessed and what could not be evaluated.)

Ear

(Include only if ear was involved.)

• Canal condition: [normal / abrasion / laceration / bleeding] (Describe extent and location if abnormal.)
• Tympanic membrane: [visualized and intact / suspected injury / unable to assess: (reason)]
• Post-procedure hearing: [Findings / unable to perform: (reason)] (Include only if baseline was assessed.)

Nose

(Include only if nose was involved.)

• Mucosal condition: [normal / abrasion / ulceration / necrosis / edema]
• Bleeding status: [none / controlled / persistent: (interventions)]
• Re-examination for additional foreign bodies: [yes / no] (Include contralateral naris; consider oral cavity and ear canals in young children or when multi-orifice insertion is suspected.)

Complications and Tolerance

• Patient tolerance: [well tolerated / poorly tolerated: (brief explanation)]
• Complications: [none / complication(s) with management provided] (Do not document "none" if complete post-procedure exam was not possible; instead state what is known and what could not be assessed.)
• Estimated blood loss: [none / minimal / quantified estimate]

Disposition and Follow-up

• Disposition: [discharge / observation / ENT consult / OR / transfer]
• Medications: [none / ear drops for canal trauma or otitis externa / nasal medications / analgesics] (Antibiotics are not routinely indicated after uncomplicated removal. List agent, dose, route, and duration when applicable.)
• Follow-up: [None indicated / ENT follow-up / Audiology follow-up / timeframe] (ENT follow-up indicated for button battery or magnet removal, significant mucosal/canal injury, suspected TM injury, retained fragments, or unsuccessful removal. Audiology if hearing loss or TM injury suspected.)
• Return precautions reviewed: [For ear: worsening pain, drainage, fever, hearing change, vertigo] · [For nose: recurrent or persistent bleeding, fever, worsening unilateral discharge or odor, increasing pain, breathing difficulty, concern for retained object]