Medical Record Review
Otitis Media—The Forest and the Trees
Editors: Lawrence F. Nazarian, MD.
Otitis media is the subject of the Guide for Record Review distributed with this issue of Pediatrics in Review. This guidebook presents a balanced approach to management while stressing those elements that contribute to accurate recordkeeping.
One responsibility shared by all who treat children with otitis media is the need to see the big picture, and proper documentation is crucial to this task. Because ear infections often occur suddenly and are usually painful, patients frequently are seen on a semi-emergent basis, so they are cared for at all hours and often by whichever provider is available. If the child is not otherwise ill, the visit tends to be straightforward and brief, and the temptation to move quickly on to the next patient is natural. Although follow-up is considered important, the return visit is easy for a parent to forget. Even if kept, this visit also tends to be brief; a busy physician seeing a normal set of ears might announce the good news and go immediately to the next responsibility. As a result, a pattern of recurrent ear infections that warrants intervention, such as further investigation of underlying factors, prophylactic medication, or referral to an otolaryngologist, could be overlooked.
One way of recognizing illness patterns that require attention is to review the child's history of otitis when he or she presents with an ear infection.
