Audiologist Template

ENT or Medical Specialist Referral Letter

A professional Audiologist template for healthcare professionals.

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Specialty

Audiologist

Used

8 times

Type

Note

Last edited

21/01/2026

Created by

Heidi Team

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About this template

Streamline your patient referral process with our ENT or Medical Specialist Referral Letter template. Designed specifically for audiologists and other medical specialists, this comprehensive template helps you clearly communicate critical patient information and audiological findings to receiving clinicians. Easily document the patient's details, reasons for referral, relevant test results (like pure tone audiometry and tympanometry), clinical history, and previous interventions. This template ensures all necessary information, such as referral objectives or specific questions, is captured for a seamless and effective referral. Utilise this template within Heidi to generate precise and professional referral letters, enhancing inter-speciality communication and optimising patient care.

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Referral Letter Referring Clinician: Dr. Sarah Jenkins, Senior Audiologist, City Hearing Clinic, sarah.jenkins@cityhearing.org, 020 7946 0001. Patient Details: Master Thomas O'Connell, born 15 May 2018, Folder Number: CHC-PED-2345, Contact Number: 07700 900300 (Parent: Mrs. O'Connell). Reason for Referral: Referral is made due to persistent fluctuating conductive hearing loss in the right ear and suspected middle ear pathology, despite several courses of antibiotics. There is a significant impact on speech and language development as reported by the parents and nursery staff. Relevant Audiological Findings: - Pure tone audiometry results: Right ear: Moderate conductive hearing loss (average 45 dB HL at 500-2000 Hz). Left ear: Normal hearing. - Tympanometry classification and reflexes: Right ear: Type B tympanogram with absent acoustic reflexes. Left ear: Type A tympanogram with present acoustic reflexes. - Otoacoustic emissions (OAE) outcomes: Right ear: Absent DPOAEs. Left ear: Present DPOAEs. - Speech discrimination or speech reception thresholds: Right ear: SRT 50 dB HL. Left ear: SRT 15 dB HL. - Screening outcomes (e.g. school-based hearing screen fail): Failed recent nursery hearing screening in the right ear. Clinical History and Background: Thomas has a history of recurrent otitis media with effusion (OME) since the age of 2, experiencing approximately 4-5 episodes per year. There is no known exposure to ototoxic medications, TB, HIV, or significant noise exposure. No family history of early-onset permanent hearing loss. Parents report persistent ear pulling and occasional reports of muffled hearing. Previous Interventions or Management: - Medical or antibiotic treatment for infections: Multiple courses of broad-spectrum antibiotics from GP, with temporary improvement only. - Audiology follow-up reviews or school-based support: Regular audiology monitoring for the past 18 months, with recommendation for nursery staff to be aware of hearing difficulties. Referral Objectives or Questions: To rule out persistent middle ear effusion requiring surgical intervention (e.g. grommet insertion) and to evaluate for any underlying anatomical abnormalities contributing to the recurrent OME. Specific questions include assessment for adenoid hypertrophy and consideration for tympanoplasty if indicated. We also seek guidance on managing the fluctuating conductive loss to minimise impact on his speech and language development.