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Ear Care Nursing Record
Name:
Address:
Date of Birth:
Occupation:
Medication:
Related to Noise/Dust?
Family History of Deafness?
Yes / No
General Health Problems:
Diabetic:
Allergies:
Verbal Consent obtained:
Note: Ototoxic drugs eg.
Streptomycin.
Assessing Nurse:
Date:
Yes / No
Yes/No
Past ENT History
Grommets In Situ
Mastoid
Cleft Palate
Recent Ear Infection
Surgery on tympanic membrane or
other ear surgery
Tympanic perforation
Ear Infection
Ear Pain
Ear Discharge
History of Impaction
Tinnitus
Vertigo
Itching
Hearing Aid
Previous Ear Irrigation
Hearing Loss
Otoscopic Examination
Tympanic membrane visible
Dryness
Scaling
Erythema
Discharge
Oedema
Pain
Wax
Amount & colour
Right Ear
Left Ear
Details
Use of Ceruminolytic Agents
How much?
How often?
What kind?
Physical Assessment of Pinna
Swellings
Lesions
Mastoid tenderness
Ear Care Nursing Record Version 1 18Jan13
Page 1 of 2
DATE
APPEARANCE OF EAR DRUM
SIGNATURE
TREATMENT GIVEN (INCLUDING ADVICE)
NOTING ANY ABNORMALITIES
Right Ear
Left Ear
Right Ear
Left Ear
Right Ear
Left Ear
Ear Care Guidelines
Page 2 of 2
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