Chart Review

• Chart review: Each student should do a thorough and independent chart review for assigned patients and record this information on a history/session worksheet; the clinic schedule with assigned patients is available in the shared OneDrive folder with appointments for Lisa Mancl in standard font and appointments for Leah Martin in italics font. Students will not see the patient with an “L” on the schedule.
• Access Electronic medical records in EPIC on your personal computer or IHDD office computer.
  • Logon to EPIC: https://access.uwmedicine.org/vpn/index.html
  • set up an EPIC filtered schedule to see Lisa Mancl and Leah Martin patients: click on the Schedule icon on the top and in the lower left column click on the Create icon and select General and name your filtered account, select Configuration and Provider and enter the provider names; complete by clicking select

• Go to the schedule for the day of your clinic and review your assigned patients, by clicking on patient name and selecting “REVIEW”. Maximize seeing medical records across all available medical centers by clicking on the Care Everywhere icon on the upper right ribbon; click “UPDATE” for each medical center and click “LOAD ALL RECORDS NOW” if it appears at the top
  • Summary in left column
    • Name: legal name, preferred name, preferred pronoun
    • Age: note age is on the day you are reviewing chart, so document expected age on appointment data; Epic calculates corrected age if child was premature
    • Language: if a language other than English is listed, open to see if they need an interpreter
    • primary care physician: list name of PCP (click on name to get clinic location)
  • Referral/ reason for visit: referral tab
  • Demographic tab
    • parent names and family
  • Hearing history
    • Newborn hearing screening
      • Review the WA EHDDI databasefor Newborn Hearing Screening/Rescreening and diagnostic evaluations; access with Firefox browser and use mother’s name as the most powerful search tool.
      • NHS is listed in NICU discharge summaries located in either the Encounters or Notes or Media tabs. You may also see documentation of NHS in other providers’ evaluations in the teams clinics.
    • Audiological history: past evaluations at IHDD and audiology clinics are in Encounters tab.
    • UW Medicine and other medical records may contain documentation of hearing screenings at a well child visit; “hearing and vision screening” results are usually at the bottom of the note.
  • Medical history
    • Neonatal history: In Notes tab: discharge summary
    • Primary care visit notes and UW Specialty Clinic reports: under Encounters tab
    • Outside reports that have been scanned in: Media tab
  • Developmental history: Under the Encounters tab, review results of past assessments by IHDD Teams providers: note if child’s development was WNL, mildly delayed, or severely delayed. The Media tab contains records and questionnaires that have been faxed to IHDD.
• Chart review forms:
  • There is a history form for general patients and a history form for patients with hearing aids; forms are in the student office and in the shared drive. These forms should serve as a guide for what information is needed in your chart review and as a tool to help you during case history with the patient. A recommended method is to use different colored ink for your notes: color 1 for your chart review notes (what is known previously); color 2 for what happens during the session (parent concerns and responses to questions, recommendations, etc). You will use the back side/2^nd page of the form for your case history with the family; your review of the child’s records will allow you to individualize the case history questions so that you can summarize what you know from past visits and referral notes. You should include notes on what you know about the child from past visits and chart notes on the back sheet of the form so that you can individualize your questions.
  • Information to obtain for chart review
  • Identifying information:
  • You will need all of the following information for every patient: name, hospital number, DOB, parent names, hometown, family physician.
  • Note the child’s early intervention program or school and educational audiologist
  • Age: Epic calculates age and corrected age; add additional days if your chart review is done in advance of the visit.
  • Hearing history: When you review the audiological reports for a child, you will want to record previous audiograms in the tables on your chart review form so that you have an adequate “picture” of this child’s hearing levels; record the data for each ear in separate tables. You should then be able to see the “holes’ and what additional data is needed for your test session and what data is old enough that warrants replication. Be thorough in your recording of previous evaluations; you should record the date, the clinic, the test method, the thresholds obtained, and the tympanogram status for a minimum of the last 2 visits. Circle the appropriate summary finding of this child’s hearing history and then transfer this
  • Perinatal/neonatal history: Record the child’s significant medical issues during the NICU indicated in the NICU discharge summary. Many infants will have medical issues such as hyperbilirubinemia, apnea of prematurity, rule-out sepsis; these are significant health conditions, but typically are not associated with significant development or hearing issues. Red flags for developmental concerns include: intraventricular hemorrhage, retinopathy of prematurity > stage 3, periventricular leukomalacia, hypoxic ischemic encephalopathy, congenital CMV. Risk factors for hearing change are noted on your history form: Family history of HL, cCMV, ECMO.
  • Developmental level: estimate the developmental level of your patient so that appropriate test methods can be selected. You may not be able to estimate the exact developmental age of the child, but you should be able to estimate if the child has age-appropriate development, a mild delay, or a severe delay and if the child has autism and/or sensory sensitivities.
  • Testing plan: The “Pediatric Audiology Assessment Guidelines” document has age-specific guidelines for appropriate test methods, test parameters, and the guidelines for expected range for a number of audiological tests. Refer to these guidelines both in your preparation for clinic and in your interpretation of test results. Given what you know about the patient, you should develop a plan for the session:
  • What questions should be asked during the case history that are specific to this child?
  • Given your estimate of the developmental level of the child, what behavioral test method will be appropriate for this child?
  • What audiometric data would you like to obtain? List the clinical information you would like to collect in descending priority, as it is likely with a young child, that you will not be able to complete everything.
  • What physiological tests could be used to complement behavioral measures or in lieu of behavioral measures?
  • If speech audiometry testing is used, what test materials are appropriate given the child’s language level in English?
  • What family resources might be pertinent?

• Hearing aid patients: For hearing aid patients, you should review the details of the child’s earmolds/ear pieces and receivers, hearing aids, hearing assistance technology and record these on your chart review form. For children with hearing aids, note the results of the last aided speech testing and previous questionnaire results. If you are not familiar with the hearing aids and/or fitting software, you should log on to the patient file in Noah and review the software on the computer in room 342.
• Parent perspective: Given what you know about the “family journey”, try to look at the appointment from the perspective of the family. What expectations and worries will they bring to the appointment? What issues/stressors/limited resources are potentially impacting the family?
• Progress: Each child and family face unique challenges in follow-up and development of skills. Children for whom we have significant concerns about their progress require more close monitoring, communicating with families about our concerns and, if need referrals to other professionals. In reviewing the chart for the child you should try to classify the concerns in the areas listed below and record on your chart review form. Resources that can help you evaluate progress are: previous clinic reports, reports from early intervention or school, reports from other clinics.

• Speech/language milestones: Use the ASHA Communication Milestones below to give you expected speech/language milestones for the child’s age and record these milestones on your chart review form. A child should have more than half of the items in their age group; children with less communication skills should be considered at high risk for communication delay and should be referred for further assessment and intervention. Additional screening tools used at IHDD include the MCHAT and the ASQ.

• Outcome Measure Questionnaires: There are a number of outcome questionnaires that can be used with parents and children, as indicated in the Pediatric Audiology Protocol. We are currently using the LittlEARS for parents of children 0 to 2 years, the PEACH for parents of children age 3 to 4 years, the CHILD for ages 5 to 8 years, and the P-APHAB for tweens and teens and SAC/SOAC for older teens. These questionnaires can be filled out by the family during the session and then scored by us before the end of the appointment. You can find Outcome Measures on the UW LEND Website and printed versions are located in the behavioral booth control room.
• Preparation for fitting/orientation: If we will be fitting new hearing technology, you will need to familiarize yourself with the devices by reading through the user manuals and program the devices prior to the appointment. Use the orientation checklists in the “IHDD Hearing Technology Guidelines” document for guidance on what you need to cover in the orientation of the devices. Devices should be pre-programmed and feedback manager should be run in the coupler prior to the visit and then final adjustments can be made during the visit.
• Parent education materials: We have compiled a variety of parent education materials that are located in a notebook in the upper cabinet in room 341 as well as in the Family Resources section of the UW LEND website. The Resource Notebook for Families of Children Who are Deaf or Hard of Hearing notebook is given to all families with children who are DHH under the age of 3 and notebooks are in the cabinets in 342; the notebook is also published in other languages, located in the Family Resources section of the website. For families with children who are DHH you can use the Sound Beginnings questionnaires to assess the family’s needs for information; forms are on the UW LEND website and printed versions are located in the Family Resource notebook in CD342.

eport Writing

• Clinical Data: All electronic clinical data should be uploaded to the shared folder so that you can use the data in your reports.
• Disposal of patient information: Due to HIPAA regulations, you are required to dispose of all written and electronic information containing patient information after you have written your reports. After you review your edited report, erase the document from your computer/flash drive. Put old chart review forms in the shredding bin in your office.

• History section of your report should “tell the story” of the patient up until the current appointment. History obtained during the case history part of the visit should be included as is relevant.
  • Name: Include the child’s first name and last name. If the child uses a nickname, put this name in quotes as part of the full name (Jonathon “Jon” Smith).
  • Age: Calculate the child’s age at the day of the visit, using the calendar to help you calculate. Use age in days for infants under 2 weeks of age, use age in weeks for children under 2 months, and round to the youngest month for older children. Use corrected age if the child is premature (< 38 weeks gestation). Corrected age:  Calculate the child’s due date by adding the number of weeks of prematurity to the date of birth. Calculate the child’s corrected age at the date of test by counting the months from the due date to the test date.  For example a child born at 29 weeks gestation on May 1, 2012: add 11 weeks of prematurity (40 weeks is term gestation) for a due date of July 17, 2012. With a test date of August 17, 2013, the child’s corrected age on that day is 13 months.
  • Reason for visit: A brief statement of the reason for the visit.
    • “hearing evaluation due to speech and language concerns”
    • “hearing evaluation due to hearing concerns”
    • “follow-up audiological evaluation and hearing aid check”
    • “hearing screening as part of the Child Development Clinic team evaluations”
  • Hearing and ear history:
    • Opening summary of hearing status:
      • For a child with known hearing differences, the opening statement should include a summary statement.

“John presents with hearing levels in the moderate range in both ears. His hearing differences are congenital and were identified at 3 weeks of age and have been stable since diagnosis. The etiology is genetic, associated with Waardenburg Syndrome.”.

“Lakiesha presents with a history of fluctuating hearing levels in the mild range associated with middle ear fluid”.

• If the child has not been previously diagnosed with hearing differences, you don’t need an opening summary of hearing levels, just a description of previous hearing testing.

“Peter passed a newborn hearing screening at birth and passed a hearing screening at his primary care physician’s office at age 4, per parent report.”

“Mary did not pass an initial newborn hearing screening during her neonatal stay at UW Medical Center; she passed the otoacoustic emissions screening in the right ear and did not pass in the left ear”.

• Previous hearing evaluations
  • Summarize the diagnoses from previous evaluations and screenings; avoid reporting the data for specific tests, unless it is crucial to do so. Describe the results from the most recent evaluation with more detail since the current findings will be directly compared to the last findings. For fluctuating or progressive hearing levels, it may be helpful to summarize additional evaluations to provide a clear picture of the hearing over time. Describe past screenings and timeline for screening. Use “pass” and “did not pass” or “refer”; do not use “fail” to describe past screenings.
• “Helen did not pass a newborn hearing screening and rescreening at UW Medical Center; at the initial screening in the hospital at 2 days of age she did not pass in both ears and at a follow-up screening at 10 days of age she did not pass in the left ear and passed in the right ear.”
• “Karen’s hearing was last evaluated in this clinic on December 10, 2012; she demonstrated hearing levels in the mild range and middle ear fluid in both ears”.
• “John’s hearing was last evaluated on July 10, 2012; he demonstrated behavioral hearing thresholds of 45 to 65 dBHL in both ears.”
• “Mary demonstrated hearing levels in the mild range from birth to age 2 and hearing levels in the moderate range from age 2 to 4”.
  • Middle ear history:
    • When describing middle ear history, a child with no previous ear infections should be described as “Mary has a negative history of ear infections”. Use the term “tympanostomy tubes”  and not ear tubes, or PE tubes.  If a child has a positive history describe the frequency of occurrence and the most recent ear infections.
    • “Steven has had approximately 3 ear infections and the last infection was 3 weeks ago”.
    • “Mark has a history of recurrent ear infections for the past two years. He received tympanostomy tubes at Seattle Children’s Otolaryngology on March 23, 2019.”
  • Etiology and Family history of childhood hearing differences:
• Describe any relatives with hearing differences since childhood and the details of their hearing that are known such as age of onset, progression, etiology. Relatives should be described as being maternal or paternal. If the child has had genetic testing or the etiology is known, describe the findings.
• “Karen has a family history of childhood hearing differences with two maternal uncles and a paternal cousin with hearing differences since birth or since childhood. Genetic testing has not been completed.”
• “Lakiesha’s hearing differences are associated with a mutation in the OTOG gene, associated with congenital mild to moderate stable hearing levels.”

• Developmental progress:

Describe the child’s expressive and receptive speech/language skills. For children who are not receiving services and are seen for an Audiology only appointment, use the ASHA Communication Checklist to determine if the child is at risk for communication delays.

“Kevin has 2 to 3 words that he uses consistently and understands simple commands. Based on the ASHA Communication Checklist, Kevin has less than half of the communication skills expected for children at his age and is, therefore, at risk for communication delays.”

“Mary speaks in short sentences, but her speech is difficult to understand”.

• Hearing Technology:

Describe the current hearing aids the child is wearing and how long these devices have been used as well as the age of first fitting. Summarize the use time across settings and any issues with retention and removal or concerns about function. Describe how the child listens to music and video. If a remote mic accessory or system is used by the family, describe how they uses it.

“Ben has worn hearing aids since 1 month of age. He currently wears Phonak Sky Marvel binaural behind-the-ear hearing aids, devices that he has had worn since June 2012   Ben and his parents report that he wears her hearing aids full-time both at home and at school. Ben listens to music and videos by streaming directly to his hearing aids from his smartphone and tablet.”

“Kate’s family uses a personal remote mic accessory (Phonak Partner Mic) in noisy settings like parties and sporting events and at the playground”.

• Intervention/school:

Indicate what early intervention program or school the child is enrolled in and identify the EI provider or the school audiologist. For school-age children, indicate if remote mic technology is used in the classroom and the type of receivers used (ear-level or soundfield). Specify if the child is receiving any special services to address communication.

“Mary and her family receive weekly birth to three services through the Listen and Talk program and their provider, Ann Smith.”

“Kerry is in 2^nd grade at Mountain View Elementary in the Northshore School District and is supported by the district educational audiologist, Allison Smith. Kerry’s teacher uses a remote mic FM/DM transmitter in the classroom and Kerry has DM receivers installed in her hearing aids. She receives support services from the school speech-language pathologist and teacher of the deaf”.

• Medical home: Indicate the primary care physician and where the child lives. If an interpreter was used for the visit, include this detail.

“Selena lives with her family in Edmonds and is followed by Dr. Jones at Edmonds Family Medicine. A Spanish language in-person interpreter was used for today’s appointment”.

• The Results section includes the data you collected during the evaluation, but not an interpretation.
  • Participation: describe the child’s behavior during the appointment if it impacted testing.
    • “Selena didn’t tolerate earphones in her ears; soundfield speaker testing was used.”
    • “The demands of the listening and head turn task of VRA was not appropriate for Kevin’s developmental skills today.”
  • Each test should include a definition of the test and a definition of typical results for that test.
  • Report if a test or stimulus condition was attempted but not successful
    • “Bone conduction BAER testing could not be completed due to Mary awakening.”
  • Behavioral Assessment: Include the audiogram and the speech audiometry table, if speech testing was completed.
  • Otoacoustic Emissions: include the DPOAE data for each ear
  • Immittance: include the tympanograms and acoustic reflex measures for each ear. Describe results of otoscopy.
  • BAER: Put BAER response wave V latencies in a table: include the level at threshold and the level just below with no response. Include a scanned copy of the BAER waveforms with right/left ears on the same side of the page as the table and in descending frequency order.
  • Hearing Technology Tables:
    • Earmolds/ear pieces: include style, modifications, color and date the earmolds were made. For RIC users include the length, type of receiver and the type/size of dome or type of custom earpiece.
    • Hearing aid/technology table: include the manufacturer and model and serial numbers and details about the program settings, volume control, frequency compression cut-off frequency. In the table, include measured soft and average aided SII from the Verifit. Use the aided SII look-up table or on the Verifit for the expected range of aided SII based on the child’s PTA at .5, 1, and 2 kHz in each ear. If hearing aid output is within 5 dB of targets, as indicated by RMSE values, indicate the frequency range; if targets cannot be achieved within 5 dB, indicate the frequency range for which targets are met. Include the estimate of datalog daily average use time and the window of time.
  • Outcome Measures
    • Include a brief description of the outcome questionnaire and the scores along with the expected range for the child’s age.
    • Results of speech audiometry measures should be described with the test conditions and results.

• The Assessment section is where you interpret all of the testing, both with a summary statement of the diagnosis and details about each of the tests. Soundfield and unmasked bone conduction thresholds represent hearing in at least one ear, whereas pure-tone earphone testing represents hearing function in each ear. Speech recognition measures are interpreted using an interpretation as well as the specific % correct.
  • Opening statement: the opening statement summarizes the diagnosis
    • Typical hearing/auditory function:

You can state that the “child has hearing levels in the typical range in both ears”  if frequency-specific thresholds were measured across a range of frequencies in both ears, with a minimum of .5 and  2 kHZ, and preferably also 4 kHz. If limited testing, such as only OAE testing was completed, you can conclude  “child is passing a hearing screening today”. If BAER testing was completed, you can conclude that child has “auditory function within the typical range in both ears”. If testing in inconclusive or inadequate data for passing a screen, you should state that “today’s testing is inconclusive regarding Joe’s hearing”.

• Hearing levels: The opening statement should summarize the child’s diagnosis based on all the testing. ” Billy demonstrates hearing levels in the moderate range and middle ear fluid in both ears; the type is conductive”. “Karen demonstrates hearing levels in the typical range in the low and mid frequencies and hearing levels in the moderate to severe range in the high frequencies; the type is sensorineural”.

• Test details: The next few sentences should specifically interpret each test that supports the diagnosis.
  • Behavioral assessment: Describe the hearing thresholds obtained by soundfield, earphone and bone conduction testing. Describe SAT/SRT as indicative of hearing sensitivity for speech stimuli as well as being a cross-check of frequency-specific thresholds. Describe speech recognition ability using % correct and descriptors.

“Specifically, Billy demonstrates behavioral sound field behavioral hearing thresholds across the frequency range at levels of 50 to 55 dBHL. He shows a soundfield speech detection threshold of 50 dBHL, showing good agreement with frequency-specific soundfield thresholds. Unmasked bone conduction testing shows an air-bone gap with bone conduction hearing thresholds of 10 to 20 dBHL; the type is conductive in at least one ear”.

“Specifically, Steven demonstrates behavioral pure-tone hearing thresholds of 0 to 20 dBHL across the frequency range in both ears. He is able to recognize words presented at a conversational level as indicated by speech recognition scores of 96% and 100% correct in the right and left ears, respectively”.

• Impact of hearing levels: Interpret unaided speech recognition measures and outcome measures questionnaires in regards to the impact of the hearing levels on the child’s access to spoken language. Include an interpretation of the unaided SII measure calculated from the child’s audiogram in Verifit.

“When speech is presented at a conversational level in quiet, he is able to identify most words (92%), but has significant challenges identifying conversational level words in noise (50%); this measure is thought to simulate typical listening situations in school and in noisy settings in the community.  These findings are supported by Mark’s mother’s responses on the PEACH questionnaire, indicating that she reports significant communication challenges for Mark in noisy settings. A calculation of the SII (speech intelligibility index), estimates that 75% of conversational speech in quiet is audible to Mark when wearing hearing aids, whereas 11% of speech is audible without hearing aids.”

• Immittance: interpret the tympanograms in regards to the function of the outer and middle ear systems in each ear.  Include an interpretation of acoustic reflex measures as these results support the diagnosis. Interpret otoscopy along with immittance measures.

“He has typical outer and middle ear function in both ears”.

“She has middle ear fluid in both ears as indicated by flat tympanograms as well as otoscopic inspection.”

“Mary demonstrates absent acoustic reflexes in the left ear, consistent with hearing differences”.

• OAE testing: OAE results are described as being present/robust or absent.

“Specifically, Karen demonstrates robust otoacoustic emissions in both ears from 2 to 8 kHz”.

• BAER testing: describe the specific BAER thresholds for all stimuli using dBeHL values.

“Specifically, BAER thresholds were measured at 75 and 80 dBeHL in both ears for 500 and 2000 Hz tone pips, respectively, indicating hearing levels in the severe range.”

• Descriptive Terminology

• Degree of Hearing Levels
  • Typical hearing: 0 to 20 dB
  • Mild hearing levels: 21 to 40 dB
  • Moderate hearing levels: 41 to 55 dB
  • Moderately severe hearing levels: 56 to 70 dB
  • Severe hearing levels: 71 to 90 dB
  • Profound hearing levels: 91 to 115 dB and no response at limits.
• Interpretation of SNR Loss Measures (BKB-SIN, HINT-C) after age-matched corrections:
  • 0-3 dB: typical performance in noise
  • 3-7 dB: Mild SNR loss; mild difficulties in noise
  • 7-15 dB: Moderate SNR loss; significant difficulties in noise
  • >15 dB: Severe SNR loss; severe difficulties in noise

• Reliability/incompleteness

If the reliability of the data is poor then this should be addressed in this section. Include what testing was attempted but could not be completed.

“Earphone testing could not be completed as Juan didn’t tolerate the earphone.”,

“Kevin responded to frequency-specific and speech stimuli inconsistently and behavioral hearing thresholds could not be established.”

“Further BAER testing could not be completed due to Mary awakening”.

• Comparison to past testing

Compare the current results to past testing to determine if the hearing levels has been stable or if there has been an improvement in hearing or progression.

• Hearing aids:
  • Appropriate gain across the frequency range for a range of speech levels at appropriate levels of aided audibility.

“Coupler measurements of the hearing aids indicate that current settings achieve target DSL values for gain for soft and average speech and aided SII values fall within the expected range for the levels of hearing. ”

• Use of programs and volume

“Kerry successfully uses a program for noisy settings that utilizes adaptive directional microphone technology to help her hear in noisy settings. She has a volume control button, but rarely uses this function”.

• Use time and maintenance routine

“The family maintains and stores the hearing aids appropriately each day. Kerry wears her hearing aids full time at school and most of the time at home, typically taking a one to two hour break when she arrives home from school”.

• Earmold fit

“Kerry’s earmolds are not fitting well due to ear growth; new impressions were made today”.

• Benefit from hearing aids as demonstrated by aided speech audiometry measures and SII

“Kerry’s hearing aids provide her with access to most speech sounds as indicated by an aided speech recognition score of 88% correct, but she has more challenges distinguishing speech in the presence of noise, as demonstrated by speech in noise score of 60% correct. Kerry demonstrates an SNR loss of 5 dB, indicating mild difficulty understanding speech in noise for her age. Aided SII electroacoustic measures estimate that 85% of average speech and 70% of soft speech is audible to Kerry when wearing her hearing aids; 24% of average speech is audible without hearing aids.”

• Remote mic/HAT
  • Does the child have access to audio and phone technology and, if needed, is the child using streaming technology?
  • Is the child using remote mic/FM technology at home and at school to help with hearing in noise?

• The Recommendations section should outline any recommendations for follow-up testing and any referrals. Recommendations should also include the “why” of the recommendation. The opening paragraph should summarize the nature and details of the discussion with the family regarding the impact of the hearing levels, the family goals, and the rationale for the subsequent recommendations listed below.

• Hearing Levels
• If hearing differences have been ruled out and the child does not have risk factors for late onset hearing change, the standard recommendation is:

” Hearing can change throughout childhood. Screen hearing yearly at regular well-child visits and in public school according to national health guidelines from age 4 to age 18. If there are concerns about a change in hearing, it is recommended that hearing be evaluated by an audiologist.”

• If the child demonstrates hearing in the typical range, but there is a risk factor for hearing change, recommend a follow-up schedule and the rationale.

“Due to Jennifer’s family history of childhood hearing differences, it is recommended that her hearing be monitored with yearly hearing evaluations, or sooner if there is a concern about a change in hearing”.

• If the child demonstrates temporary conductive hearing differences, provide recommendations for both medical management and audiological monitoring as appropriate.

“Due to Mary’s history of recurrent ear infections and evidence of hearing levels in the mild range, it is recommended that she be referred to an otolaryngologist for consideration of tympanostomy tubes. It is recommended that Mary’s hearing and middle ear status be monitored closely with a re-evaluation within 2 months.”

• For reports for children with an initial diagnosis of permanent hearing differences or for a consultation, recommendations should include an opening paragraph that describes the impact of hearing levels, the family goals, and the rational for recommendations.

“Steven’s parents, Sally and Sam, were counseled regarding Steven’s hearing differences and the implications for his communication development and learning. It was discussed that infants who are hard of hearing or deaf benefit from early identification and intervention. If the family’s goals are for the child to develop spoken language skills, hearing aids and cochlear implants are technology for providing improved auditory access for development of listening and spoken language along with enrollment in an early intervention program that supports technology use and listening and spoken language development through parent education. Alternately, if the family’s goals are for their child to develop visual communication skills using American Sign Language (ASL), an early intervention program can support ASL development through family education. Finally, the family goals may include their child developing both listening and spoken language with use of hearing technology as well as sign language skills; hearing technology and an intervention program that support both listening and spoken language development as well as sign language development can support these goals. The family was given the “Resource Notebook for Families or Children who are Deaf or Hard of Hearing” published by the WA State Department of Health. As a result of these discussions the following recommendations were made:

• timeline for ongoing audiological assessments to monitor hearing

“It is recommended that Mark’s hearing be monitored closely with hearing evaluations every three months, until hearing has been determined to be stable and then yearly, thereafter.”

• medical evaluation by otolaryngology and further evaluations to explore the etiology of the HL if not completed previously

“The etiology of Mark’s hearing differences is unknown at this time and his parents are advised to pursue additional testing in the future including a  CT/MRI scan of the ear, and genetic and CMV testing. For these evaluations, he is referred to …”

• hearing technology

If the child is identified with hearing differences or if a hearing differences are confirmed, indicate if the child is a candidate for hearing technology and provide a general description of the type of devices that are appropriate. It may be helpful to describe why the child could benefit from hearing technology and link to the family goals if those include using listening and spoken language.

“It is recommended that Mark be fit with binaural hearing aids in line with his family’s goals for him to have access to spoken communication. At the conclusion of this appointment, earmold impressions were taken. Mark will return to this clinic within the next month for his initial fitting with earmolds and hearing aids.”

• Intervention
  • early intervention and referral to family resource coordinator, if under age 3
  • educational support in school, if school-age

Provide specific recommendations for how the child’s hearing levels can be addressed in school, including description of remote mic/FM-DM technology, and support services from educational audiology

“It is recommended that Mark have access to a remote mic/FM-DM system in school to help him hear the teacher above the classroom noise.”

• Developmental support
  • If there are concerns about the child’s development and the child is enrolled in school, provide recommendations for evaluations to determine child’s candidacy for special education services. If the child is not enrolled in school, provide recommendations for private developmental assessments, or by the public schools Child Find preschool assessment team, or refer to the family resource coordinator in their county for determining candidacy for birth to three services.

“Based on the ASHA Communication Milestones checklist, Mark is at risk for language delay. It is recommended that he be evaluated by a speech/language specialist at his school to get a more detailed evaluation of his skills and determine if he could benefit from speech/language therapy.”

• For children with hearing aids, the recommendations should include specific recommendations about the following:
  • Hearing technology Use and Care
    • hearing aid wear time and care

“It is recommended that Evin continue to wear her hearing aids at the current settings full-time at home, in the community, and at school. Her family is encouraged to increase her use of hearing aids at home after school”.

“It is recommended that Mary’s parents continue to maintain the hearing aids with battery checks, cleaning of earmolds, and nightly storage in a charging/drying kit”.

• retention/removal recommendations

“It is recommended that Mary’s parents use a hat or headband to improve retention of the hearing aids and to deter her removal.”

• use of remote mic technology

“It is recommended that Evin continue to use a remote mic/FM-DM system in conjunction with her hearing aids in school to assist her in hearing the teacher when distance and noise create listening challenges. It is also recommended that the family consider use of a remote mic/FM-DM system at home and in the community to help her hear in challenging and noisy settings.”

• access to audio devices

“It is recommended that Daniel use the direct connectivity of his hearing aids to listen to music and videos on his