ENT cases

What this does

ENT (ear, nose, and throat) cases in Usystems let you document findings and procedures related to otolaryngology—conditions affecting the ears, nasal passages, sinuses, throat, larynx, and related structures. An ENT case creates a complete clinical and financial record: clinicians see the patient's history and current condition, and billing captures the services rendered.

Before you start

• You have permission to create medical cases. If you see "Access denied" when opening a medical record, contact your administrator.
• The patient already exists in Usystems and has a medical record open.
• You have a clear clinical reason for the ENT case—for example, a complaint of hearing loss, sinus infection, sore throat, or vocal change.
• The services and procedures you plan to document (e.g., "Otoscopy," "Rhinoscopy," "Throat Examination") are already set up in your service catalog.

Steps

1. Open the patient's medical record. Go to Medical Cases Open in Usystems and find the patient. If they don't have a medical record yet, create one first.

2. Click Create New Case or the plus (+) button. A dialog appears listing available case types (Dental, Neurosurgery, ENT, etc.).

3. Select ENT as the specialty. The ENT case template opens, showing fields for chief complaint, history, and examination findings.

4. Record the chief complaint or reason for visit. Enter the patient's main symptom or reason for the ENT visit—for example, "Hearing loss," "Ear pain," "Chronic sinusitis," or "Hoarseness."

5. Document the examination findings. Depending on the ENT case template, you may have fields for:

   • Otoscopy (examination of the ear canal and eardrum)
   • Rhinoscopy (examination of the nasal passages)
   • Throat and larynx examination (pharynx, tonsils, vocal cords)
   • Hearing assessment (if applicable)
   • Other findings (e.g., nasal discharge, swelling, inflammation)

   Fill in the relevant sections based on your clinical examination.

6. Add procedures if applicable. If the visit involved a procedure (ear wax removal, nasal spray administration, throat culture), add it to the case. Some ENT cases may not include procedures if the visit is consultation-only.

7. Record any medications or treatments prescribed. If you prescribed antibiotics, nasal medications, ear drops, or other treatments, document them in the case notes or treatment section.

8. Save the case. Click Save or Done. The ENT case is now part of the patient's medical record. If the case is later invoiced, the documented services appear on the bill.

Accounting impact

ENT services are billed like other medical services: by service code and time/quantity. When you save an ENT case with specific procedures or services documented, the billing system captures those service charges. The revenue is recorded against your ENT or otolaryngology service income account. If the case is invoiced, each service appears as a line item, making it clear to the patient what they are being charged for.

Tips & common mistakes

• Be specific with findings. Instead of "Normal," describe what you actually saw—"ear canals clear, eardrums intact" or "nasal septum deviated to the left." This helps future clinicians and supports accurate diagnosis coding.
• Document all relevant findings even if normal. A note saying "throat examination normal, no exudate" is more valuable than "throat OK."
• Link procedures to the examination. If you performed a procedure, make sure it's recorded as part of the case so billing is complete.
• Use the case for follow-up. If the patient needs a follow-up visit, you can create a separate ENT case for the next visit or add notes to the existing case, depending on your workflow. This creates a visible history of the patient's ENT care over time.

---