Ear Lavage Procedure Documentation Form
Document the key details of the ear lavage procedure using this form. The title "Ear Lavage Procedure Documentation Form" is used consistently throughout.
Patient Initials or Encounter ID
*
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Indication for Ear Lavage
*
Pre-Procedure Assessment/Findings
Solution Used
*
Please Select
Warm saline
Hydrogen peroxide
Carbamide peroxide
Water
Other
Laterality
*
Left
Right
Both
Amount of Solution Used (mL)
Patient Tolerance
*
Well tolerated
Mild discomfort
Procedure stopped due to intolerance
Procedure Outcome
*
Cerumen removed successfully
Partial removal
No significant removal
Follow-up or Additional Instructions
Submit Documentation
Should be Empty: