Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Cerumen impaction removal.
SOAP
Subjective (S):
Hearing Loss:
Inquire about the degree and duration of hearing loss (unilateral or bilateral).
Ear Symptoms:
Ask about tinnitus (ringing in the ear), ear fullness, or autophony (hearing your own heartbeat in the ear) associated with the cerumen impaction.
Previous Treatment:
Briefly document any previous attempts at cerumen removal by the patient or other healthcare providers.
Objective (O):
Otoscopy:
Perform otoscopy using an otoscope or video otoscope to visualize the ear canal and tympanic membrane (eardrum).
Describe the amount, consistency, and location of the cerumen impaction (completely or partially occluding the ear canal).
Assess the visibility of the tympanic membrane.
Assessment (A):
Cerumen Impaction:
Confirm the diagnosis of cerumen impaction based on otoscopy findings.
Plan (P):
Cerumen Removal:
Describe the method used for cerumen removal, such as:
Irrigation with warm water
Cerumen loop removal
Otologic suction
Document the success of cerumen removal and visualization of a normal-appearing tympanic membrane.
Hearing Improvement:
Briefly note any improvement in hearing reported by the patient after cerumen removal.
Follow-up:
If cerumen impaction is severe or recurrent, discuss the need for follow-up visits or preventive measures (e.g., ceruminolytic drops).
Additional Notes:
Document any unexpected findings during otoscopy (e.g., inflammation, otorrhea).
Briefly mention any patient education provided regarding cerumen impaction and ear care.