Documenting an ENT list
Operation notes, post-operative reviews, discharge advice, work certificates and letters to the GP.
The morning after an adult tonsillectomy
Day one after tonsillectomy, cold steel dissection with bipolar haemostasis.
Two doses of oxycodone overnight. Eating soft food and drinking well this morning.
Fossae clean, no clot, no bleeding. Afebrile.
Home today. Paracetamol 1 g QID and ibuprofen 400 TDS, regular for ten days. Oxycodone 5 mg, ten tablets, for breakthrough.
Secondary bleed risk is highest between days five and ten. Any bleeding at all, straight to the nearest emergency department. Off work two weeks, rooms at three weeks.
Progress
Day 1 post tonsillectomy (cold steel, bipolar haemostasis). Oxycodone ×2 overnight. Tolerating soft diet and fluids.
Examination
Tonsillar fossae clean, no clot, no bleeding. Afebrile.
Discharge
- Paracetamol 1 g QID and ibuprofen 400 mg TDS, regular for 10 days
- Oxycodone 5 mg PRN, 10 tablets
- Bleeding advice: present to the nearest ED with any bleeding; risk highest days 5 to 10
- Off work 2 weeks. Review in rooms at 3 weeks
What leaves with him
- Discharge letter
- The analgesia schedule, the bleeding advice in plain words, diet and the review date.
- Work certificate
- Two weeks off, from the same dictation.
- Letter to the GP
- Procedure, findings and the rooms review, with histology to follow if tissue was sent.
