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
 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 If Yes, tick choices below:
Date of Readmission ____/_____/_____  N/A for this patient
Number of days after initial procedure:______ N/A for this patient
Blood transfusion
YesNoif 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Noif 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 : SignaturePrint Name

Adapted from: National Prospective Tonsillectomy Audit, RoyalCollege of Surgeons of England (2005)