Why a patient's ringing in the ears should be documented in the encounter section of the EHR

Title: Where to log a new symptom in the EHR? The encounter section matters more than you think

A client starts talking about a high-pitched ringing in the ears. It’s not a big, dramatic complaint, but it’s real, it’s current, and it could steer the next steps in care. So, where should you put that information in the electronic health record (EHR)? The quick answer: in the encounter. Here’s why that choice makes sense and how to make the most of it when you’re taking notes during a visit.

Think of the four main EHR homes you’ll juggle

If you’ve ever peeked at an EHR, you’ve probably noticed a few familiar sections. Here are four that come up often:

• Medical history: A snapshot of past health issues, surgeries, allergies, and lingering conditions.

• Medication list: What the patient is currently taking, including dosages and recent changes.

• Review of systems (ROS): A broad, system-by-system screening for symptoms the patient might be experiencing.

• Encounter: The live record of a specific visit or interaction, including the symptoms discussed, the clinician’s assessments, and the plan.

Each section serves a purpose, but they’re not interchangeable. That ringing in the ears isn’t a historical note or a medication item; it’s something the patient is presenting right now.

So, why is the encounter the right home for this symptom?

Let me explain with a straightforward logic you’ll appreciate on busy days:

• It’s current and visit-specific. The patient arrives with a symptom that’s relevant to this particular encounter. The encounter section is designed to capture what happened during that visit, including the patient’s description, editors’ notes, and the plan for next steps.

• It informs decision-making. If you log the ringing in the ears in the encounter, other clinicians who read the chart later will see what was discussed, what tests or referrals were suggested, and what follow-up is planned.

• It supports continuity of care. A symptom may evolve or resolve over time. Having it documented in the encounter creates a clear thread that ties together the patient’s current condition, the assessment, and the treatment decisions for this visit.

• It helps with billing and coding. The encounter section is the natural place to document the reason for the visit and the provider’s plan, which feeds into accurate coding and reimbursement.

A quick aside on ROS vs Encounter

Sometimes students wonder if a symptom belongs in ROS or in the encounter. Here’s a simple rule of thumb: ROS is a broader screening of symptoms across body systems, used to identify issues the patient may not mention spontaneously. If the ringing in the ears is a newly reported symptom during this visit, you still place it in the encounter because that’s where you tie the symptom to this specific interaction, its onset, the patient’s concerns, and the plan you discuss. ROS might then reflect this symptom as part of the larger system review, but the primary documentation of the visit’s content lives in the encounter.

What to document in the encounter about the ear-ringing symptom

To make the encounter meaningful—and useful to anyone who reads it later—include a concise but complete description. Here are elements that typically belong in the encounter note when a patient reports a new symptom like tinnitus:

• Symptom description: Direct quote or paraphrase of the patient’s words about the ringing. Note quality (high-pitched), onset (when it started), duration (constant or intermittent), and intensity (mild, moderate, severe).

• Context and onset details: Any recent events, medications, loud noises, or head injuries around the time the symptom began.

• Associated factors: Dizziness, hearing loss, headaches, fullness in the ears, nausea, or changes in balance.

• Alleviating or aggravating factors: Silence versus noise exposure, time of day, caffeine or alcohol use, stress.

• Patient concerns and impact: How the symptom affects sleep, concentration, daily activities, or mood.

• Brief assessment plan: Any immediate observations, suggested tests (e.g., audiology referral, hearing test), or referrals discussed.

• Plan and follow-up: What you told the patient to watch for, any red flags, and a clear follow-up plan or next appointment.

A practical example (kept concise for the chart)

Encounter note snippets might look like this in real life:

• “Pt reports acute onset high-pitched ringing in both ears starting 2 days ago. No associated vertigo. Denies fever, trauma, or recent loud noise exposure. No hearing loss reported at this time. ROS negative for other ENT symptoms except muffled hearing reported later in the visit. Plan: schedule audiology screening, consider ENT referral if symptoms persist beyond 2 weeks; discuss caffeine reduction and stress management; follow-up in 1 week by phone or return visit as needed.”

That keeps the message clear: what the patient said, what you considered during the visit, and what happens next.

What not to do (and common missteps to avoid)

• Don’t tuck new symptoms into medical history simply because they feel like “past issues.” That rings false for current concerns and can mislead future care.

• Don’t bury the symptom in the medication list. Meds are for prescriptions, not the patient’s current complaints.

• Don’t keep ROS as a catch-all and omit the encounter details. ROS is valuable, but the encounter is where the current visit’s story lives.

• Don’t skip the plan. The encounter is the place to summarize the discussion about next steps, tests, or referrals and to set expectations with the patient.

A tiny digression that connects to real-world care

Documentation isn’t just about charts and codes. It’s about safety, trust, and clear communication. When a patient hears, “We’ve noted your ringing and will check it further,” they feel heard. That trust—combined with precise notes—helps the care team coordinate, from a quick phone check by a nurse to a scheduled audiology appointment with a specialist. It’s the quiet backbone of good care that often gets overlooked in conversations about medical records.

Tips to keep your encounter notes sharp

• Use direct quotes when the patient’s words add clarity. A simple line like, “‘It’s a high-pitched tone, mostly in the right ear,’” can be powerful.

• Stay concrete with timing and evolution. “Started two days ago, constant since then, no relief with over-the-counter ear drops” communicates a lot.

• Link symptoms to potential next steps. If tolerance to sound is affected, note that you discussed a referral or a test.

• Be precise but not overlong. A few clear sentences can do the job; you don’t need a dissertation for a routine visit.

• Include a brief plan. Even a sentence or two about what the patient agreed to or what you recommended helps downstream clinicians.

Bringing it all together

Here’s the heart of the matter: a symptom reported in the moment of care belongs in the encounter. It’s not just a label; it’s a living record of what the patient is experiencing right now, how the team chooses to approach it, and what happens next. This approach keeps care cohesive, supports safety, and helps every clinician who reads the chart understand the patient’s path.

If you’re exploring the realm of physical assessment topics and how clinicians organize patient information, you’ll notice the same rhythm across many parts of the EHR. The voice you use in the encounter—clear, precise, and compassionate—becomes the thread that ties the patient’s story to a thoughtful plan. And that’s the core of excellent care: listening well, documenting clearly, and guiding the patient forward with confidence.

A final nudge of encouragement

Next time you jot down a new symptom during a visit, pause for a moment. Ask yourself: If someone reads this note in a month, will they understand what the patient said, why it matters, and what we planned to do? If the answer is yes, you’ve written an encounter that serves the patient—and your team—well. And that kind of clarity, in the end, is what makes quality care feel, well, human.