Clients verbal consent obtained to use transcribing software.
Hearing Assessment:
Patient Information:
- John Smith
- 01/01/1960
- Male
- 01 November 2024
Previous Hearing Aids?
- No
Reason for Referral:
- Patient reports difficulty hearing in noisy environments and requests a hearing assessment.
COSI - Established or Reviewed
- Asking for repeats with general conversations: 3
- Asking for repeats with background noise: 4
- TV up louder than others would like: 2
- Difficultly hearing people on the phone: 3
- Socially Active/Meetings: 2
History:
- Patient reports gradual hearing loss over the past 5 years, worse in the left ear. Difficulty following conversations in background noise. No history of ear infections or trauma.
- No significant past medical history. No previous surgeries.
- Patient is a retired teacher, lives with his wife, and enjoys social activities.
Examination:
- Otoscopy: External auditory canals clear bilaterally. Tympanic membranes intact and pearly grey.
- Tympanometry: Type A tympanograms bilaterally.
- Pure tone audiometry: Mild to moderate sensorineural hearing loss bilaterally, worse in the high frequencies.
- Speech audiometry: Speech reception thresholds (SRT) consistent with pure tone averages. Word recognition scores reduced, especially in the left ear.
Assessment:
- Mild to moderate sensorineural hearing loss bilaterally.
- Sensorineural hearing loss, bilateral.
Clinical Comments:
- Patient is motivated to improve his hearing and is open to hearing aids.
- Discussed communication strategies, including reducing background noise and facing the speaker.
- Results explained to the client.
Plan:
- Recommend hearing aids for both ears. Discussed different hearing aid styles and features.
- Schedule a follow-up appointment for hearing aid fitting and orientation.
Hearing Device Advice, including Free To Client: (If proceeding with Top Up Aids - DEVICE SELECTION TO BE COMPLETED)
- Top Up Aids Discussed: Yes
- Quotation Completed: Yes
- Batteries & Maintenance Discussed: Yes
- WANT completed if fitted with device: Yes
OTHER SERVICES MAY BE COMPLETED:
- Report to GP: Yes
- Complex Client: No
- Results Explained to the Client: Yes
- Claim 610 or 810: No
- Advice regarding Rehabilitation Services (ITEM 670) if client not being fitted with a device: No
Clinician Information:
- Dr. Jane Doe
- [Clinician Signature]
- 01 November 2024
Clients verbal consent obtained to use transcribing software.
Hearing Assessment:
Patient Information:
- [Patient Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Date of Birth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Gender] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Date of Assessment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Previous Hearing Aids?
-[Yes or no](If yes, what type of hearing aid and how old)
Reason for Referral:
- [Reason for referral] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
COSI - Established or Reviewed
- [Asking for repeats with general conversations:] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Asking for repeats with background noise:] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [TV up louder than others would like:] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Difficultly hearing people on the phone:] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Socially Active/Meetings:] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History:
- [Describe current hearing issues, reasons for visit, discussion topics, history of presenting complaints etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Examination:
- [Describe otoscopic findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Describe tympanometry results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Describe pure tone audiometry results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Describe speech audiometry results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assessment:
- [Summary of findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Clinical Comments:
- [Clients Expectations/Motivation and attitude towards hearing rehabilitation](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Discussion of communication strategies/tactics] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Results explained to the client] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [Recommended treatment or management plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Follow-up appointments or referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Hearing Device Advice, including Free To Client: (If proceeding with Top Up Aids - DEVICE SELECTION TO BE COMPLETED)
- [Top Up Aids Discussed] (Yes or No)
- [Quotation Completed] (Yes or No)
- [Batteries & Maintenance Discussed] (Yes or No)
- [WANT completed if fitted with device] (Yes or No)
OTHER SERVICES MAY BE COMPLETED:
- [Report to GP] (Yes or No)
- [Complex Client] (Yes or No)
- [Results Explained to the Client] (Yes or No)
- [Claim 610 or 810] (Yes or No)
- [ Advice regarding Rehabilitation Services (ITEM 670) if client not being fitted with a device:] (Yes or No)
Clinician Information:
- [Clinician Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Clinician Signature] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Date] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
