"History:"
Lily Smith was seen for an audiologic evaluation, referred by Dr. Jones due to concerns about speech delay. Lily Smith attends St. Mary's Primary School and has an IEP to help with educational concerns related to auditory processing disorder. Lily Smith was accompanied by her mother, Sarah Smith, at today’s appointment. Sarah Smith denied/reported Lily Smith having otalgia, otorrhea, tinnitus, vertigo, family history of childhood hearing loss, or loud noise exposure.
"Results:"
Otoscopy revealed normal tympanic membranes bilaterally. Tympanometry revealed Type A tympanograms bilaterally. Acoustic reflex thresholds were present at normal levels bilaterally. Distortion Product Otoacoustic Emissions were present bilaterally. Speech reception thresholds were 20 dB bilaterally. Pure-tone testing was completed via air and bone conduction using standard procedures with insert earphones. Results were obtained with excellent reliability. Testing for the right ear revealed mild, high-frequency sensorineural hearing loss. Testing for the left ear revealed mild, high-frequency sensorineural hearing loss.
Word recognition scores were 96% in the right ear and 98% in the left ear. Speech in noise testing via the QuickSIN revealed a score of 5 dB SNR loss.
"Impressions:"
Lily Smith presents with mild, bilateral, high-frequency sensorineural hearing loss.
"Recommendations:"
1. Hearing aids are recommended for both ears.
2. Follow-up audiologic evaluation in six months.
3. Referral to speech therapy.
"It was a pleasure working with Lily Smith. Thank you for allowing me to participate in her care."
"History:"
[patient name] was seen for an audiologic evaluation, referred by [referral source] due to concerns about [reason for referral]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [patient name] attends [school name] and has an IEP to help with educational concerns related to [diagnosis]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [patient name] was accompanied by [accompanying person] at today’s appointment. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [accompanying person] denied/reported [patient name] having otalgia, otorrhea, tinnitus, vertigo, family history of childhood hearing loss, or loud noise exposure.
"Results:"
Otoscopy revealed [otoscopy findings]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Tympanometry revealed [tympanometry findings]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Acoustic reflex thresholds were [acoustic reflex findings]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Distortion Product Otoacoustic Emissions were [DPOAE findings]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Speech reception thresholds were [SRT findings]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Pure-tone testing was completed via air and bone conduction using standard procedures with insert earphones. Results were obtained with excellent reliability. Testing for the right ear revealed [right ear thresholds]. Testing for the left ear revealed [left ear thresholds]
Word recognition scores were [word recognition findings]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Speech in noise testing via the QuickSIN revealed [QuickSIN findings]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
"Impressions:"
[patient name] presents with [impressions]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
"Recommendations:"
(list recommendations numbered below)
"It was a pleasure working with [patient name]. Thank you for allowing me to participate in [his/her/their] care."
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from