Glaucoma, Otitis Media and Hearing Loss Clinical Documentation

Glaucoma

Glaucoma

• Type (specify eye(s) affected)
    --Open angle
    --specific type (primary, low-tension, pigmentary, capsular, residual
       stage)
    --Narrow angle (angle-closure)
    --specific type (e.g. acute, chronic, intermittent, residual stage),
    --Glaucoma in diseases, such as:
    --Amyloidosis
    --Diabetes
    --Other (specify)
    --Glaucoma suspected
• Secondary glaucoma due to:
    --Drugs
    --Eye inflammation
    --Trauma
    --Other disorders
• Stage (specify eye(s) affected)
    --Mild
    --Moderate
    --Severe, Advanced, End-stage
    --Indeterminate
• Document any associated diagnoses/conditions

Otitis Media

• Incidence:
    --Acute/subacute
    --Acute recurrent
    --Chronic
• Laterality:
    --Right ear
    --Left ear
    --Bilateral
• Types:
• Serous
• Suppurative or Nonsuppurative
• Tubotympanic
• Atticoantral
• Allergic
• Mucoid
• Document if associated with:
    --Spontaneous rupture of tympanic membrane
    --Without spontaneous rupture of tympanic membrane
    --Infectious or other external agent
    --Exposure to environmental tobacco smoke
• Document any other associated diagnoses/conditions

Hearing Loss

• Laterality:
    --Bilateral
    --Unilateral
• Extent of hearing loss:
    --Left/right ear with unrestricted hearing on the contralateral side
• Types:
    --Conductive
    --Sensorineural
    --Mixed
    --Other (specify)
• Document any associated diagnoses/conditions