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EAR, NOSE AND THROAT CLINIC FOLLOWUP NOTE

 

DATE OF VISIT: XX/XX/XXXX

 

SUBJECTIVE: The daughter brings this patient in because the right ear had started draining.  That ear has a tube in it.  The patient was strongly advised to leave the hearing aid out of that ear.

 

OBJECTIVE: Under the microscope, the tube is still in position but there is gross pus in the ear canal.  It was cleaned and 5 drops of ofloxacin placed in the ear.

 

ASSESSMENT: Acute otitis media on the right.

 

PLAN: Ofloxacin 5 drops b.i.d. x10 days.  I also put in a prescription for Claritin 10 mg per day.  The patient was advised to return in 2 weeks if the ear continued to drain.  Otherwise, he will keep the appointment next month.

Patient Name
Patient Medical Record Number
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This is a medical transcription sample report in the form of a SOAP note. To read more about medical transcription soap notes please visit Anatomy of a SOAP Note.
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