Peritonsillar Abscess Drainage Procedure Note

Date/Time of procedure: [Date and time]

Location: [ED / clinic / OR / bedside / other]

Procedure performed: [needle aspiration / incision and drainage / both]

Laterality: [right / left / bilateral]

Primary operator: [Name, credential]

Assistant(s): [Name(s), credential(s)] (Omit if none)

Indication

[Brief clinical context establishing medical necessity, 3–5 sentences] (Include presenting symptoms relevant to peritonsillar abscess such as severe unilateral sore throat, trismus, muffled voice, and dysphagia; summarize key oropharyngeal findings such as soft palate swelling, uvular deviation, and tonsillar displacement; clearly state why drainage is indicated. If diagnostic uncertainty exists between abscess and cellulitis, state this and how it was addressed.)

Pre-Procedure Assessment

Airway and aspiration risk: [Ability to handle secretions, respiratory status, degree of trismus, airway rescue readiness, patient positioning] (Always address airway first. If unable to fully assess, document why and mitigation steps taken.)

Relevant risks and modifiers: [Anticoagulation status, bleeding disorders, relevant allergies, pertinent comorbidities] (Omit if none)

Imaging: [Modality and relevant findings characterizing the collection] (Omit if none obtained)

Time-Out

Time-out performed immediately before procedure start verifying correct patient, procedure, and laterality; allergies reviewed; equipment readiness confirmed including suction; team in agreement.

Consent

[Consent obtained from patient / surrogate / emergent exception]. The nature and purpose of drainage, material risks (bleeding, aspiration, airway compromise, failure to drain requiring repeat procedure or ENT intervention), benefits, and alternatives were discussed. Questions were answered, understanding confirmed, and the patient agreed to proceed. (If standard consent was precluded by emergent circumstances, document the specific rationale.)

Anesthesia

• Topical: [Agent, concentration, application method] (Omit if none)
• Local infiltration: [Agent, concentration, total volume, injection site(s)]
• Procedural sedation: [None / see separate sedation record / brief summary including medications with doses and times, monitoring, and recovery status]
• Tolerance: [Adequate / inadequate, patient tolerance description]

Procedure

(Chronological narrative of what was done. Include only components performed.)

• Preparation and targeting: [Anatomic target, landmarking method, adjuncts used, positioning and suction readiness]
• Needle aspiration: [Needle gauge, entry point, depth-limiting strategy, number of passes, aspiration outcome] (Include only if performed)
• Incision and drainage: [Instrument, incision size and location, blunt dissection if performed, irrigation if used] (Include only if performed)
• Hemostasis and completion: [Hemostasis method if needed, criteria for stopping]
• Immediate response: [Notable changes such as improved trismus or voice] (Omit if none)

(If procedure aborted, document specific reason and subsequent plan.)

Findings

Drainage: [Estimated amount in mL, character, consistency, color] (If no pus obtained, state this and note clinical interpretation.)

Specimen: [Culture obtained: yes / no] [If yes: specimen type and tests ordered] [If no: reason] (Must be explicitly documented either way)

EBL: [mL / minimal]. Hemostasis [achieved / method used].

Complications: [None / description of event and management]

Post-Procedure Status and Disposition

• Airway/respiratory: [Handling of secretions, voice quality, oxygenation, respiratory distress present or absent]
• Oral intake: [Tolerating PO / NPO / PO trial result]
• Observation: [Duration] (Include if applicable)
• Medications: [Antibiotics, steroids if used, analgesics with agents and doses]
• Disposition: [Discharged with stable airway / Admitted to service with reason]

Follow-Up and Return Precautions

Follow-up: [ENT / primary care] within [timeframe], [appointment scheduled / referral placed / patient to arrange].

Return precautions discussed: Worsening breathing or stridor, inability to swallow or handle secretions, worsening pain or trismus, neck swelling, fever, significant bleeding, inability to take oral medications or fluids.

Signature: [Name, credentials, date/time]