Laryngitis Progress Note Template
Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Subjective:
Voice quality: Describe the patient’s current voice quality (hoarseness, breathiness, complete loss of voice).
Cough: Inquire about the presence, frequency, and character of cough (productive vs. non-productive).
Sore throat: Assess the severity and duration of sore throat pain.
Swallowing difficulty: Ask about any difficulty or pain with swallowing.
Associated symptoms: Mention any other relevant symptoms like fever, runny nose, congestion, fatigue.
Objective:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
ENT exam findings:
Focus on the larynx – assess vocal cord mobility (indirect laryngoscopy if possible).
Examine the pharynx (back of the throat) for redness or inflammation.
Check for nasal congestion or discharge.
Optional: If suspected bacterial infection, document presence of purulent (pus-filled) secretions.
Assessment:
Diagnosis: State the diagnosis of laryngitis (acute or chronic if applicable).
Cause: If possible, identify the underlying cause of laryngitis (viral infection, vocal strain, overuse).
Plan:
Treatment:
Outline recommendations for voice rest and vocal hygiene.
Mention medications if prescribed (e.g., pain relievers, lozenges, humidification).
Advise on specific measures to address the underlying cause (e.g., avoiding irritants for vocal strain).
Follow-up:
Schedule the next clinic visit based on symptom severity and expected resolution timeframe.
Instruct the patient to return sooner if symptoms worsen or do not improve within a specified timeframe.