Otitis Externa Visit Note

Date: [Encounter date]

Patient: [Patient name]

Provider: [Clinician name]

Visit Type: [Initial evaluation / Recheck / Wick removal]

Subjective

Chief Complaint: [Patient-stated complaint including laterality and duration] (Use patient's own words when possible.)

HPI: [Narrative covering onset, duration, progression; laterality; pain severity 0–10 and characteristics including triggers and effect on sleep; associated symptoms such as pruritus, otorrhea, hearing change, vertigo; precipitating factors such as water exposure, cotton swab use, hearing aids, recent instrumentation; prior treatment and response; red flag symptoms including fever, facial weakness, severe deep pain, trismus. Explicitly note diabetes, immunocompromise, tympanostomy tubes, known TM perforation, or prior ear surgery if present.] (For recheck visits, focus on interval change and treatment response.)

Pain Assessment: [Current pain score 0–10; worst pain level; analgesics tried and effectiveness] (Note if pain appears disproportionate to exam findings.)

Objective

Vitals: [Relevant vital signs] (Include temperature if febrile concern; may omit for routine rechecks.)

General: [Appearance and distress level]

Ear Exam:

• Right Ear: [External ear and periauricular findings; tragus and pinna traction tenderness; canal status including edema severity, erythema, debris, discharge; tympanic membrane status] (State "TM visualized and intact/non-intact" or "TM not visualized due to [reason]." If otoscopy limited, document what was attempted and what could not be determined. Never infer TM integrity.)
• Left Ear: [External ear and periauricular findings; tragus and pinna traction tenderness; canal status; tympanic membrane status as above]

(Include only sides examined.)

Procedures

[Aural toilet / Wick placement / Both]: [Indication; technique; findings after cleaning; patient tolerance] (Omit section if no procedures performed. If wick placed, note plan for removal.)

Assessment

[Primary diagnosis with laterality and severity] (e.g., "Acute otitis externa, right, moderate, with canal edema limiting TM visualization.") [Key supportive findings. Differential diagnoses if diagnostic uncertainty exists.] (If high-risk features present—periauricular extension, immunocompromised host, granulation tissue, cranial nerve findings—document concern for complicated or necrotizing otitis externa.)

Plan

• Topical Therapy: [Drug, formulation, dose, frequency, duration, laterality] (If TM status uncertain or non-intact, document selection of non-ototoxic preparation.)
• Drug Delivery: [Aural toilet performed / Wick placed / Both / Not required] (If wick placed, include removal timing.)
• Systemic Antibiotics: [Agent and dosing with explicit justification] (Include only if prescribed for infection extending beyond canal, inability to deliver topical therapy, host factors, or concern for necrotizing OE.)
• Analgesia: [Medication and dosing appropriate to pain severity]
• Ear Care: [Instructions to keep ear dry, avoid inserting objects; drop administration technique reviewed; after-visit summary provided]
• Follow-up: [Timing and indication] (48–72 hours if not improving; 2–3 days for wick check; lower threshold for high-risk patients.)
• Return Precautions: [Worsening pain after 48–72 hours; fever; spreading redness; facial weakness; vertigo; inability to instill drops]