Attendees: Dr. Sarah Jones (Audiologist), Patient: John Smith.
Case History:
Presenting Problems: Patient reports difficulty hearing conversations in noisy environments and struggles to understand speech, especially when multiple people are talking.
Situational Needs: Patient identifies challenges with hearing at restaurants, family gatherings, and while watching television.
Onset of Hearing Loss: Gradual onset over the past 5 years, patient first noticed difficulty hearing in social situations.
Tinnitus: Patient reports intermittent tinnitus in the left ear, described as a high-pitched ringing. Monaural.
Vertigo: No history of vertigo.
Noise Exposure: Patient denies any significant occupational or recreational noise exposure.
Family History: Mother has a history of age-related hearing loss.
Ear History:
- Ear Pain: No ear pain reported.
- Ear Operations: No surgical history.
- Discharge: No discharge reported.
ENT Consults: Patient seen by ENT specialist 2 years ago, no significant findings.
Vision: Patient wears glasses for reading.
Memory: No cognitive concerns reported.
Hands/Shoulders: No motor impairments.
Living Situation: Patient lives with his wife in a quiet suburban home.
Auditory Assessment:
Otoscopy: Normal appearance of the ear canals and tympanic membranes bilaterally.
Pure Tone Audiometry: Air conduction thresholds: Right ear: 30 dB HL at 1000 Hz, 40 dB HL at 2000 Hz, 50 dB HL at 4000 Hz. Left ear: 35 dB HL at 1000 Hz, 45 dB HL at 2000 Hz, 55 dB HL at 4000 Hz. Bone conduction thresholds within normal limits.
Word Recognition Scores (WRS): Right ear: 80% at 65 dB HL. Left ear: 75% at 65 dB HL.
Tympanometry: Type A tympanograms bilaterally, normal middle ear compliance.
Speech-in-Noise Testing: Patient performed poorly on speech-in-noise testing.
Review of Results: Patient demonstrates a mild to moderate sensorineural hearing loss bilaterally, worse in the high frequencies.
Rehabilitation Program:
COSI Discussion: Discussed specific communication difficulties and goals for improvement using the Client-Oriented Scale of Improvement (COSI).
Motivation and Attitude: Patient is highly motivated to improve his hearing and communication.
Communication Strategies: Discussed strategies for managing background noise, such as moving closer to the speaker and using visual cues.
Hearing Aid Discussion:
FTC Device Features: Discussed features of hearing aids available under the NHS.
T-Coil Explained: Telecoil function explained.
Device Recommendation: Recommended a behind-the-ear (BTE) hearing aid with directional microphones and noise reduction features.
Top-Up Explained: Discussed potential for private upgrades.
Additional Technology: Recommended a remote microphone for use in noisy situations.
Quotation Given: A quotation for private hearing aids was provided.
Style Discussion: Discussed BTE and receiver-in-canal (RIC) hearing aid styles.
Technology Model and Level: Discussed and selected a mid-level technology.
Domes vs. Earmolds: Discussed the pros and cons of domes and earmolds.
Fitting and Follow-Up Timeline: Scheduled fitting appointment for 2 weeks from today, with follow-up appointments at 2 weeks and 1 month.
Hearing Aids Ordered: Ordered a pair of BTE hearing aids, model XYZ, serial numbers provided.
Report to GP/ENT: Report to be sent to the patient's GP.
Attendees:
[List all clinicians, audiologists, students or support people present at the appointment] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Case History:
Presenting Problems:
[describe the client's main concerns regarding hearing or communication difficulties] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Situational Needs:
[describe specific listening situations where support is needed – e.g. television, phone, group conversations] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Onset of Hearing Loss:
[describe whether onset was sudden or gradual, and relevant timeline] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Tinnitus:
[describe tinnitus presence, severity, and whether monaural or binaural] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Vertigo:
[note any history or current complaints of vertigo] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Noise Exposure:
[describe any history of occupational or recreational noise exposure] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Family History:
[mention any family history of hearing loss or related conditions] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Ear History:
- Ear Pain: [mention if present or not]
- Ear Operations: [mention any surgical history]
- Discharge: [note if any otorrhoea was reported]
(Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
ENT Consults:
[summarise any ENT specialist consultations] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Vision:
[note any visual impairments relevant to hearing or communication] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Memory:
[mention any cognitive concerns] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Hands/Shoulders:
[mention any motor impairments affecting device handling] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Living Situation:
[describe living arrangements, support persons, or environment factors] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Auditory Assessment:
Otoscopy:
[describe visual inspection of ear canal and tympanic membrane] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Pure Tone Audiometry:
[document air and bone conduction thresholds] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Word Recognition Scores (WRS):
[record scores and test conditions] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Tympanometry:
[describe tympanogram type and middle ear compliance] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Speech-in-Noise Testing:
[record results from SIN testing if conducted] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Review of Results:
[summary of audiometry findings discussed with patient] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Rehabilitation Program:
COSI Discussion:
[describe discussion on communication needs vs hearing loss using Client-Oriented Scale of Improvement (COSI)] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Motivation and Attitude:
[note client’s motivation and readiness for hearing rehabilitation] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Communication Strategies:
[discussed strategies for managing background noise, speaker positioning, etc.] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Hearing Aid Discussion:
FTC Device Features:
[features of funded or trial devices explained to patient] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
T-Coil Explained:
[describe whether telecoil function was discussed] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Device Recommendation:
[recommended hearing aid model, brand or type] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Top-Up Explained:
[discussion of private co-payments or upgrades] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Additional Technology:
[other assistive listening devices or accessories recommended] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Quotation Given:
[record if hearing aid or device quotation was provided] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Style Discussion:
[discussion of hearing aid styles: RIC, BTE, ITE, ITC, CIC, IIC] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Technology Model and Level:
[model discussed and selected (e.g. premium, standard)] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Domes vs. Earmolds:
[discussion of acoustic coupling options] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Fitting and Follow-Up Timeline:
[planned timeline for fitting and follow-up appointments] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Hearing Aids Ordered:
[details of devices ordered including model, serial number if applicable] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Report to GP/ENT:
[mention if a report was prepared for the GP or ENT specialist] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, 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 the transcript.)
