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.
  • Access Electronic medical records in EPIC on your personal computer or CHDD office computer.
    • Logon to EPIC: https://access.uwmedicine.org/vpn/index.html
    • set up an EPIC filtered schedule to see Lisa Mancl 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 Mancl; 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
    • Demographic tab
      • parent names (under “additional information”) and family home (under “contact information”)
    • 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 Notes or Media tab.
      • Audiological history: past evaluations at CHDD 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 CHDD 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 CHDD.
    • Referral/ reason for visit: referral tab

 

  • Chart review forms:
    • There is a history form for general patients and a history form for patients with hearing aids; forms are in room 341 and in the shared drive folder. 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/2nd 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 and then . 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, home town, 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 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.
    • Testing plan: The “Pediatric Audiology Assessment Guidelines” 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 compliment 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, 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.

 

Green=no concern Yellow=slight concern Red=significant concern
Audiologic ·       Stable HL

·       Complete audiogram

·       Fluctuating HL

·       Complete audiogram

 

Incomplete audiogram

Hearing Technology Full time use

 

Part-time use

 

Limited/no use

 

Remote Mic and HAT technology Consistent use

 

Part-time/Inconsistent use No use
Developmental progress Age-appropriate skills Concerns about mild delays Concerns about severe delays

 

  • Speech/language milestones: Use the developmental checklists below to give you expected speech/language milestones for the child’s age (corrected age) and record these milestones on your chart review form.
Age Receptive Expressive
1-2 months Quiets to sound

Startles to loud sounds

Coos
6 months Localizes to sound Babbles with variety of sounds
12 months Responds to name

Follows simple commands

Jargons

Uses a few words consistently

18 months Understands questions

Understands 50 words

Uses 10-20 words

Imitates many words

24 months Understands two-step commands

Understands over 200 words

Uses 30-50 words

Uses 2-word phrases

30 months Understands complex language (size, quantity, prepositions, etc) Consistently uses 2 to 3 word phrases
36 months Understands more complex language (verbs, time concept, etc) Converses in complex sentences with some articulation differences

 

  • 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.
  • 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 “CHDD Hearing Technology” document for guidance on what you need to cover in the orientation of the devices. Devices should be pre-programmed prior to 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 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 341; 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 and support:
    • Sound Beginnings Family Questionnaire
    • Sound for Life Family Questionnaire
    • My Sound Life Questionnaire

 

 

Age Receptive Expressive
1-2 months Quiets to sound

Startles to loud sounds

Coos
6 months Localizes to sound Babbles with variety of sounds
12 months Responds to name

Follows simple commands

Jargons

Uses a few words consistently

18 months Understands questions

Understands 50 words

Uses 10-20 words

Imitates many words

24 months Understands two-step commands

Understands over 200 words

Uses 30-50 words

Uses 2-word phrases

30 months Understands complex language (size, quantity, prepositions, etc) Consistently uses 2 to 3 word phrases
36 months Understands more complex language (verbs, time concept, etc) Converses in complex sentences with some articulation differences

Report 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 form 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 screening” or “hearing rescreening”
      • “hearing evaluation due to hearing concerns”
      • “follow-up audiological evaluation and hearing aid check”
      • “hearing evaluation 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 hve 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”; do not use “fail” or “refer” 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 with 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 the OTOG gene, associated with congenital mild to moderate stable hearing levels.”

 

  • Developmental progress:

Describe the child’s expressive and receptive speech/language skills. Look to the developmental guidelines for age-appropriate skills.

“Kevin has 2 to 3 words that he uses consistently and understands simple commands”.

“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 both at home and at school and any issues with retention and removal or concerns about function. Describe how the child uses the phone, listens to music/computer, TV/video. If a remote mic system is used, describe how the family 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 she 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 2nd grade at Mountain View Elementary in the North Shore School District. Kerry’s teacher uses a remote mic FM/DM transmitter in the classroom and Kerry has DM receivers installed in her hearing aids, provided by the school audiologist, Allison Smith. She receives weekly speech therapy with the school speech/language pathologist”.

  • 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.
    • 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
    • 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 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 with a check; 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 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 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”.

  • 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, indicating hearing levels in the moderate range in at least one ear. 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 levles 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, particularly in noisy settings. A calculation of the SII (speech intelligibility index), based on Mark’s hearing levels, estimates that 75% of conversational speech in quiet is audible to Mark. “

  • 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 differneces”.

  • 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 70 and 75 dBeHL in both ears for both 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 Normal/near normal 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 due to patient refusal”,

“Kevin could not be conditioned to provide consistent responses to both frequency-specific and speech stimuli and behavioral hearing thresholds could not be established.

“Steven demonstrates behavioral responses to frequency-specific stimuli, but due to the inconsistency of his responses, threshold levels 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 demonstrates good ability to distinguish speech while wearing her hearing aids as evidenced by an aided speech recognition score of 88% correct. She does show a decrease in her ability to distinguish speech in the presence of noise, as demonstrated by speech in noise testing score of 60% correct. Kerry demonstrates an SNR loss of 5 dB, indicating a 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 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.

 

  • If hearing differences have been ruled out and the child does not have risk factors for late onset hearing loss, 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 confirmation of a permanent hearing differences, recommendations should include:
    • Opening paragraph describing discussion of impact of hearing levels family goals, 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 testing. For these evaluations, he is referred to Seattle Children’s Otolaryngology Clinic (206-987-2105).”

 

  • 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 aids and provide a general description of the type of hearing aids 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. At the conclusion of this appointment, bilateral 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. This recommendation will be forwarded on to the educational audiologist in the Seattle School District along with specific recommendations for receivers that will be compatible with the hearing aids that will be ordered.”

 

  • 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.

“Mark demonstrates some speech articulation issues. It is recommended that he be evaluated by speech/language specialists 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 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 from his smartphone and videos on his tablet. “

Report templates are located in the shared OneDrive folder.

Sample reports are located in the shared OneDrive folder.

Where Pediatric Clinical Care and Leadership Training Intersect
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Chart Review and Report Writing Guidelines

Chart Review

  • Chart review: Each student should do a thorough and independent chart review for every patient on the schedule and record this information on a history/session worksheet. Electronic medical records in EPIC are available to view on your personal computer or on the computer in room 341. Review the permanent blue file for patients with hearing technology for any additional information not found in Epic.
    • Logon to EPIC: https://access.uwmedicine.org/vpn/index.html
    • set up an EPIC filtered schedule to see Lisa Mancl (Mon, Tue, Wed) or Jennifer Long (Fri) patients
    • click on the Schedule icon on the top
    • in the lower left column click on the Create icon and select General and name you filtered account, select Configuration and Provider and enter Mancl or Long; complete by clicking select
  • Go to the schedule for the day of your clinic and review each patient, by clicking on patient name and selecting “REVIEW”.
    • Header
      • Name: legal name, preferred name, preferred pronoun
      • Language/interpreter
      • primary care physician: click on icon to find the location of the pcp OR do an internet search
    • Demographic tab on left
      • parent names and family home
    • Newborn hearing screening
      • UW NICU: Mindscape Transcripts: discharge summary
      • UW Newborn nursery: Mindscape Transcripts: interdisciplinary discharge report
      • Media tab: discharge summary from hospital outside UW Medicine
    • Medical history:
      • In Mindscape Transcripts review chart notes for additional information from the neonatal stay including social work notes, and nursing notes
      • Primary care visit notes and UW Specialty Clinic reports: under Encounters
      • Outside reports that have been scanned in: Media tab
    • Details about reason for visit: referral tab
  • Chart review forms:
    • There is a history form for general patients and a history form for patients with hearing aids; forms are in room 341 and on the website. 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 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 and then . 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, home town, family physician.
      • Note the child’s early intervention program or school.
      • Age: You will need to calculate the child’s age at the day of the visit (use 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).
    • 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 loss; 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 3 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 had during the NICU stay, as indicated in the NICU discharge summary. Many infants will have medical issues such as hyperbilirubinemia, apnea of prematurity, r/o 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 of grades > 1/2, retinopathy of prematurity > stage 3, periventricular leukomalacia, hypoxic ischemic encephalopathy, congenital CMV.
    • 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: 1) age appropriate development, 2) mild delay, 3) severe delay.
    • Testing plan: The “Pediatric Audiology Protocol” on the website has age-specific guidelines for appropriate test methods, test parameters, and the guidelines for expected normal 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:
    • Case History:What questions should be asked during the case history that are specific to this child?
    • Test plan: Given your estimate of the developmental level of the child, what diagnostic test method (ABR, VRA, CPA, conventional) will be appropriate for establishing thresholds with 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 compliment threshold measures to strengthen the diagnosis? What speech audiometry measures 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, 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 faces 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.

 

Green=no concern Yellow=slight concern Red=significant concern
Audiologic ·         Stable HL

·         Complete audiogram

·         Fluctuating HL

·         Complete audiogram

 

Incomplete audiogram

Amplification Full time HA use

 

Part-time HA use

 

Limited HA use

 

FM and HAT ·         Consistent FM use

·         Consistent HAT use, if needed

Part-time FM use

Inconsistent HAT use

Limited FM use
Developmental progress Age-appropriate skills Concerns about mild delays Concerns about significant delays

 

  • Speech/language milestones: Use the developmental checklists located on the website to give you expected speech/language milestones for the child’s age (corrected age) and record these milestones on your chart review form. For example, if the child you’re seeing is 18 months of age, you should record that the expected sp/lang milestones are “15 to 20 words, 2-word phrases, follows simple directions”.
  • 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 8 years, and the P-APHAB for children ages 9 to 12 years and SAC/SOAC for teens. These questionnaires can be filled out by the family during the session. You or your classmate will need to quickly score the questionnaire to interpret for the family.
  • 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. In addition, you will need to program the devices prior to clinic. Use the checklists in the “CHDD Hearing Technology” document for guidance on what you need to cover in the orientation of the devices.
  • Parent education materials: We have compiled a variety of parent education materials that are located in a notebook in the upper cabinet in room 342 as well as on the UW LEND Audiology website. The Resource Notebook for Families of Children Who are Deaf or Hard of Hearing notebook is given to all families with children with permanent hearing loss under the age of 3 and notebooks are in the cabinets in 341. For families with children with permanent hearing loss, you can use the Sound Beginnings/Sound for Life parent and teen questionnaire to assess the family’s needs for information and support; give this brief questionnaire to the family at the beginning of the session.

Report Writing

  • Clinical Data:
    • All forms (audiogram, tympanogram, VRA worksheet, ABR worksheet) should be completely filled out with patient name, hospital number, and test date, as well as all test details. Transfer hearing thresholds from VRA/ABR worksheet to an audiogram.
    • Tape tympanograms on the back of audiogram/worksheet with right ear data on the right side of the page and left ear data on the left side of the page.
    • At the end of the clinic, put all the hard copies of data in an empty blue chart or in the child’s permanent blue audiology chart and put in the “Completed Patients” standing file in room 341. Audiology charts cannot be removed from CHDD.
  • 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 receive your edited report, erase the document form your computer/flash drive. Bring your chart review-history forms to your next visit to CHDD and put in the shredding bin in 341.

 

  • History section of your report should “tell the story” of the patient up until the current test. 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 screening” or “hearing rescreening”
      • “hearing evaluation due to hearing concerns”
      • “follow-up audiological evaluation and hearing aid check.”
      • “hearing evaluation as part of the Child Development Clinic team evaluations”
      • If the child is seen as part of a specific clinic (Child Development Clinic, Cardiac Neurodevelopmental Follow-up Clinic), include this detail.
    • Hearing history:
      • Opening summary of hearing status:
        • For a child with a known hearing loss, the opening statement should include a summary of the child’s hearing loss. The etiology, the age of onset, age of diagnosis and stability of the hearing loss should be summarized.

“John presents with a bilateral moderate sensorineural hearing loss. His hearing loss is thought to be congenital and was diagnosed at 3 weeks of age. John’s hearing loss has been stable since diagnosis. The etiology is genetic, associated with Waardenburg Syndrome.”.

        • If the child has not been previously diagnosed with hearing loss, you don’t need an opening summary of hearing loss, 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”.

“Brian presents with a history of persistent conductive hearing loss associated with middle ear fluid”.

      • Previous hearing evaluations:
        • Describe past screenings and timeline for screening. Use “pass” and “did not pass”; do not use “fail” or “refer” to describe past screenings.
        • Summarize the diagnosis 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 loss, it may be helpful to summarize additional evaluations to provide a clear picture of the hearing loss over time.
            • “Karen’s hearing was last evaluated in this clinic on December 10, 2012; she demonstrated a mild conductive hearing loss and middle ear fluid”.
            • “John’s hearing was last evaluated on July 10, 2012; he demonstrated behavioral hearing thresholds of 45 to 65 dBHL in both ears.”
      • 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 episode.
        • “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.”
    • Perinatal/neonatal History:
      • Include any significant risk factors for childhood hearing loss.
      • “Ben was born at 27 weeks gestation, 880 grams. His neonatal history is significant for congenital cytomegalovirus infection”.
  • Family history of childhood hearing loss:
      • Describe any relatives with hearing loss since childhood and the details of their hearing loss that are known such as age of onset, progression, etiology. Relatives should be described as being maternal or paternal.
      • “Karen has a family history of childhood hearing loss. She has two maternal uncles with congenital permanent hearing loss and a paternal cousin with permanent hearing loss with onset at age 5.”
  • Developmental progress:
      • Describe the child’s speech/language skills both expressive and receptive.
      • “Kevin has 2 to 3 words that he uses consistently and understands simple commands”.
      • “Mary speaks in short sentences, but her speech is difficult to understand”.
  • Hearing Aids:
      • 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 both at home and at school and any issues with retention and removal or concerns about function. Include details about program/volume control use and the family maintenance routine.
      • “Ben has worn hearing aids since 1 month of age. He currently wears Oticon Safari Super Power binaural behind-the-ear hearing aids, devices that she 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. His parents maintain his hearing aids with daily checks and cleaning and listening checks and store the aids/molds in a drying kit every night.”
  • HAT:
      • Describe how the child uses the phone, listens to music/computer, TV/video. If a remote mic system is used, describe how the family uses it.
      • “Ben listens to music and computer audio from loudspeakers. He sometimes removes his hearing aids to listen to a music via earphones.”
      • “Kate’s family uses a personal remote mic system (Phonak Roger Pen and Roger 15 receivers) 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. 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’s teacher uses a remote mic FM/DM transmitter in the classroom and Kerry uses FM/DM receivers attached to her hearing aids that are provided by the school audiologist. She receives weekly speech therapy with the school speech/language pathologist”.
  • Medical home:
      • Indicate the primary care physician and where the child lives. If an interpreter was used for the visit, include this detail.
      • “Kerry lives with her family in Edmonds and is followed by Dr. Jones at Edmonds Family Medicine.”
  • The Results section includes the data you collected during the evaluation, but not an interpretation.
    • Each test should include a definition of the test and a definition of normal results for that test.
    • Report if a test or stimulus condition was attempted but not successful
    • Behavioral Assessment: Include a scan copy of the audiogram. Make sure that your audiogram symbols are legible and there are no errors in the audiogram. If you need to re-write your audiogram there are forms on the class website. In your scan you need only include the audiogram, key, and the speech audiometry table; you do not need to scan the part of the page with patient identification, etc.
    • Otoacoustic Emissions: include a scan copy of the DPOAE data for each ear using only the DPgram with response across frequency.
    • Immittance: include a scan copy of the tympanogram and acoustic reflex measures for each ear. Adjust the size to be small enough, but still legible. Include 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. Paste in 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 Aids and Earmolds:
      • Model and Settings: include the manufacture and model and details about the program settings, volume control and frequency compression cut-off frequency.
      • Earmolds: include style, modifications, color and date the earmolds were made
      • Electroacoustic verification data: Enter data from the Verifit printout in a table in your report for soft and average speech targets and measured values. In the table, include measured aided SII from the Verifit printout. Use the aided SII look-up table for the expected range of aided SII based on the child’s PTA at .5, 1, and 2 kHz in each ear. For children with PTA >90 dB, there are no norms. Include the serial numbers from the fitting report in the table.
      • Datalogging: include the estimate of 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 the descriptors of excellent, fair, etc as well as the specific % correct.
    • Opening statement: the opening statement summarizes the diagnosis
      • Normal hearing/auditory function: You can state that the “child has normal hearing in both ears”  if frequency-specific, ear-specific thresholds were measured across a range of frequencies in both ears, with a minimum of .5 and .2kHZ, and preferably also 4 kHz. If limited testing was completed, you can conclude “ child is passing a hearing screening today. If BAER testing was completed, you can conclude that child has “normal auditory function in both ears”.
      • Hearing loss: The opening statement should summarize the child’s diagnosis based on all the testing. ” Billy demonstrates a moderate conductive hearing loss and middle ear fluid in both ears”. “Karen demonstrates normal hearing in the low and mid frequencies and a bilateral high frequency sensorineural hearing loss that slopes from mild to severe”.
    • 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, indicating a hearing loss in the moderate range in at least one ear. Unmasked bone conduction testing shows an air-bone gap with bone conduction hearing thresholds of 10 to 20 dBHL, consistent with a hearing loss that is conductive in nature 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 demonstrates excellent ability 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 loss: Interpret unaided speech recognition measures and outcome measures questionnaires in regards to the impact of the hearing loss 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 (50 dBHL) from one speaker along with noise (multi-talker babble at 45 dBHL) from the opposite speaker, he shows fair to poor ability (50%) to understand speech; 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, particularly in noisy settings. A calculation of the SII (speech intelligibility index), based on Mark’s degree of hearing loss, estimates that 75% of conversational speech in quiet is audible to Mark. “
      • 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 normal 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 a significant hearing loss”.
      • 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 70 and 75 dBeHL in both ears for both 500 and 2000 Hz tone pips, respectively, indicating a hearing loss in the severe range.”
      • Descriptive Terminology
        • Degree of hearing loss
          • Normal hearing: 0 to 20 dB
          • Mild hearing loss: 21 to 40 dB
          • Moderate hearing loss: 41 to 55 dB
          • Moderately severe hearing loss: 56 to 70 dB
          • Severe hearing loss: 71 to 90 dB
          • Profound: 91 to 115 dB and no response at limits.
        • Interpretation of speech audiometry measures:
          • 90-100%=excellent
          • 80-90%=good
          • 70-80%=fair
          • 50-70%=poor
          • <50=very poor
          • Using 25 words lists, significant differences between conditions =>20% difference.
        • Interpretation of SNR Loss Measures (BKB-SIN, HINT-C) after age-matched corrections:
          • 0-3 dB Normal/near normal 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 due to patient refusal”,
        • “Kevin could not be conditioned to provide consistent responses to both frequency-specific and speech stimuli and behavioral hearing thresholds could not be established.
        • “Steven demonstrates behavioral responses to frequency-specific stimuli, but due to the inconsistency of his responses, threshold levels 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 loss has been stable or if there has been an improvement in hearing or progression of the hearing loss.
  • Hearing aids:
    • Interpret the hearing aid verification.
      • “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 degree of hearing loss. “
    • 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; impressions were made today”.
    • Benefit from hearing aids as demonstrated by aided speech audiometry measures and SII
      • “Kerry demonstrates good ability to distinguish speech while wearing her hearing aids as evidenced by an aided speech recognition score of 88% correct. She does show a decrease in her ability to distinguish speech in the presence of noise, as demonstrated by speech in noise testing score of 60% correct. Kerry demonstrates an SNR loss of 5 dB, indicating a 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.”
    • Remote mic/HAT
      • Does the child have access to audio and phone technology and, if needed, is 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 loss, the family goals, and the rationale for the subsequent recommendations listed below.
    •  If hearing loss has been ruled out and the child does not have risk factors for late onset hearing loss, 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 a child’s hearing be evaluated by an audiologist.”
    • If the child demonstrates normal hearing, but there is a risk factor for late onset hearing loss, recommend a follow-up schedule and the rationale.
      • “Due to Jennifer’s family history of childhood onset hearing loss, 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 loss, provide recommendations for both medical management and audiological monitoring as appropriate.
      • “Due to Mary’s history of recurrent ear infections and evidence of conductive hearing loss, 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 loss or confirmation of a permanent hearing loss, recommendations should include:
      • Opening paragraph describing discussion of impact of hearing loss, family goals, rational for recommendations
        • “Mark’s mother, Marion, was counseled regarding the diagnosis of a sensorineural hearing loss and its implications on Mark’s speech and language development, and education. It was discussed that children with hearing impairment benefit from early identification and intervention. If the family goals are for the child to use listening and spoken language for the primary communication, hearing technology will maximize the child’s auditory access, communication, and learning. The sooner that a child is using hearing technology, the sooner the child will have improved access to sound and communication.”
      • 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 loss 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 testing. For these evaluations, he is referred to Seattle Children’s Otolaryngology Clinic (206-987-2105).”
      • Hearing technology
        • If the child is identified with a hearing loss or if a hearing loss is confirmed, indicate if the child is a candidate for hearing aids and provide a general description of the type of hearing aids 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. At the conclusion of this appointment, bilateral 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 loss 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. This recommendation will be forwarded on to the educational audiologist in the Seattle School District along with specific recommendations for receivers that will be compatible with the hearing aids that will be ordered.”
      • 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.
        • “Mark demonstrates some speech articulation issues. It is recommended that he be evaluated by speech/language specialists 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 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 from his smartphone and videos on his tablet. “
Report Templates

Use the following templates as the start for writing a report.

Report template-diagnostic-eval

Report-template-hearing-aid-check-hearing-eval

Report-template-screen