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Otorhinolaryngologist (ENT Specialist) Template

ENT REPORT

A professional Otorhinolaryngologist (ENT Specialist) template for healthcare professionals.
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About this template

Need a clear and concise ENT report? This ENT report template is designed for Otorhinolaryngologists (ENT specialists) to document patient encounters efficiently. It covers essential sections like patient history, examination findings, diagnosis, and treatment plans. This template helps streamline the documentation process, ensuring all critical information is captured accurately. With Heidi, the AI medical scribe, this template can be quickly populated from your consultation transcript, saving you time and improving the quality of your clinical notes. Get organised and improve your ENT documentation today!

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Patient: Mrs. Evelyn Carter 1 November 2024 History Complaints – Mrs. Carter presents with a three-week history of right ear pain, accompanied by a feeling of fullness and reduced hearing. She reports no fever, but does note occasional mild dizziness. The symptoms are worse at night. Medication – Mrs. Carter is currently taking Lisinopril 10mg daily for hypertension and a daily multivitamin. Illnesses – Mrs. Carter has a history of hypertension, well-controlled with medication. She denies any previous ear problems or surgeries. **Examination** "Ears Right:" Right tympanic membrane is erythematous and slightly bulging. There is a small amount of clear fluid visible behind the tympanic membrane. No perforation is noted. "Left:" Left tympanic membrane appears normal, with good light reflex. No fluid or inflammation is observed. Audiogram – Audiometry reveals mild conductive hearing loss in the right ear, consistent with fluid in the middle ear. Diagnosis – Acute otitis media, right ear. Plan – Prescribe Amoxicillin 500mg three times daily for 7 days. Advise Mrs. Carter to return for a follow-up appointment in two weeks to assess resolution of symptoms and hearing. Provide patient education on the importance of completing the full course of antibiotics. Thank you. Kind regards
"Patient:" (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) [Date of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single line.) **History** Complaints – [Description of the patient's presenting complaints, symptoms, and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.) Medication – [List of current medications including dosage and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.) Illnesses – [Summary of relevant past medical history and co-morbidities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.) **Examination** "Ears Right:" [Findings from the examination of the right ear, including appearance, discharge, and any other relevant observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.) "Left:" [Findings from the examination of the left ear, including appearance, discharge, and any other relevant observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.) Audiogram – [Results and interpretation of the audiogram] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.) Diagnosis – [Clinical diagnosis based on history, examination, and investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.) Plan – [Proposed management plan, including further investigations, treatments, referrals, and follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a single paragraph.) "Thank you." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "Kind regards" (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care. Use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned, do not state that it has not been mentioned — simply leave the relevant placeholder or section blank. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript. Do not include any patient quotes.)
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Specialty

Otorhinolaryngologist (ENT Specialist)

Used

6 times

Type

Note

Last edited

10/14/2025

Created by

Gustav Smook

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