Audiologist Template

Pediatric Audiogram Template

A professional Audiologist template for healthcare professionals.

Use template Browse templates

Specialty

Audiologist

Used

12 times

Type

Note

Last edited

12/08/2025

Created by

Amanda Levy

Use template

About this template

Looking for a clear and concise way to document pediatric audiology evaluations? This Pediatric Audiogram Template is designed for audiologists to efficiently record patient history, test results, impressions, and recommendations. This template helps streamline the documentation process, ensuring all essential information is captured accurately. It's perfect for detailing otoscopy findings, tympanometry results, and hearing thresholds. With Heidi, this template can be quickly populated from your visit transcript, saving you time and improving the quality of your clinical notes. This template is ideal for audiologists seeking a structured approach to pediatric audiology documentation.

Preview template

"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."