Audit of Tonsil and Adenoid Surgery, MRHT.
Questionnaire 2: Post Operative Complications
Questionnaire 2: To be completed by Medical Personnel for Post Operative Complications
for Tonsillectomy and Adenoid Surgery carried out from X to X.
Patient MRN :
_______________
DOB
____ /_____ / ___
Date of re-admission
____ /_____ / ___
Date of Initial Operation ____/_____/____
Hospital where original procedure was performed:  MRHT

Other:________________________
For surgeries performed elsewhere, i.e not in MRHT, this is where data collection ceases)
Section 1: Complication during initial stay: Yes  No
If Yes, tick choices below:
Post operative outcome(more than one option possible)

Delayed Discharge
(Please answer questions in Delayed discharge box)

Return to theatre
(Please answer questions in Return to theatre box)

Blood transfusion
Number of Units___________________

N/A original procedure performed elsewhere (not in MRHT)
Delayed Discharge
Reason for delay (more than one option possible)

Pain(adynophagia)
 Tonsil bleed
 Adenoid bleed
 Vomiting

Bleeding
 Other:__________________________________________

N/A original procedure performed elsewhere(not in MRHT)
Return to theatre:
 Yes  No
 N/A for this patient
If Yes, number of hours after initial procedure________ hours
Bleeding site(more than one option possible): Tonsil bed
Tongue base  Adenoid

Not Known  Other(specify)_____________________________________________
Discharge date: ____/_______20___
Section 2: Readmission within 28 days of initial surgery: Yes  No
Date of Readmission
____/_____/_____
Number of days after initial procedure:______________
Blood transfusion

Yes

No


If Yes, tick choices below:
N/A for this patient
N/A for this patient
if yes, number of units________

N/A for this patient
Reason for readmission (more than one option possible): 
Pain
 Fever  Tonsil bleed
 Adenoid bleed  Vomiting  Not known  Other (specify)_______________________________
Return to theatre

Yes

No
if yes, number of days after initial procedure___________days
Bleeding site(more than one option possible): Tonsil bed
Tongue base  Adenoid

Not Known  Other(specify)_____________________________________________
Haemostasis management: Suturing  Diathermy  Pillar to pillar procedure  N/A
Other Management of post tonsillectomy bleed (more than one option possible)  Silver nitrate
 Hydrogen peroxide gargle  Packing  N/A for this patient
Completed by : Signature
Print Name
Date:
Adapted from: National Prospective Tonsillectomy Audit, Royal College of Surgeons of England (2005)
www.tonsil-audit.org