👂 Ear Irrigation or Microsuction Template

❓ Why is this important?

• Accurate assessment of suitability for irrigation or microsuction

• Documentation of history, contraindications, and examination findings

• Recording of procedure details, consent, outcomes, and complications

• Compliance with Local Enhanced Service (LES) requirements (where commissioned)

• Consistent coding for audit, continuity of care, and medico-legal protection

📊 High-level overview of the specification requirements

• Recording patient symptoms and relevant history

• Identifying risk factors and contraindications

• Documenting examination findings of the canal and tympanic membrane

• Capturing consent, method used, and outcome of procedure

• Recording complications, aftercare advice, and follow-up

• Using the correct codes for LES claims and reporting

📌 What do you need to know?

📑 Local Enhanced Service (LES) Section

• Where a Local Enhanced Service exists, the coded information for payment and reporting is shown in a separate section at the top of the template.

• This section is automatically included by Primary Care IT — you do not need to search for or load a separate template.

• The template also provides direct links to the LES specification and supporting guidance.

📝 Assessment

• Select if assessment for ear syringing is appropriate or contraindicated

• Record appointment type (initial or follow-up)

• Capture presenting symptoms: hearing loss, blocked sensation, pain, discharge, vertigo, tinnitus

🧾 Other Relevant History

• Hearing aid use

• Use of earwax softeners/oil before appointment

• Past ear problems: infections, previous wax removal, perforation, mastoidectomy, tympanoplasty, grommets

⚠️ Risk Factors

• Medical conditions (e.g. diabetes, immunosuppression, eczema, psoriasis)

• Medications (e.g. anticoagulants, antiplatelets)

👂 Examination

• Document presence, side, and consistency of wax

• Note occlusion (complete/partial)

• Record canal features (normal, swollen, erythematous, infection, tenderness, foreign body, devices)

• Assess tympanic membrane appearance, colour, and light reflex

🛠️ Procedure

• Confirm risks discussed and consent obtained

• Record method: irrigation, microsuction, or manual removal

• Select ear(s) treated and outcome (success/partial/not completed)

⚠️ Complications

• Tick if none

• If present: pain, bleeding, dizziness, infection, traumatic perforation

📋 Follow-up and Advice

• Canal clear or residual wax advice

• Aftercare: avoid cotton buds, keep ear dry for 48 hours, olive oil drops for prevention

• Arrange review or ENT referral if needed

💡 Hints and Tips

• Always document risks discussed and consent obtained before procedure

• Record wax consistency and occlusion to guide whether irrigation or microsuction is best

• Check medical or medication-related risk factors before attempting procedure

• Use the LES-coded fields at the top of the template to ensure accurate reporting and claims

• Provide clear aftercare advice to reduce infection risk and recurrence