Cochlear Implant Candidacy Evaluation Report

Patient: [Full name] | DOB: [MM/DD/YYYY] | MRN: [Medical record number]

Date of Service: [MM/DD/YYYY] | Clinic/Location: [Clinic name and address]

Referring Clinician: [Name, credentials]

Audiologist: [Name, credentials, license number]

Communication Mode: [spoken language / ASL / AAC / other]; [interpreter used: yes / no]; [caregiver present: yes / no]

Reason for Referral: [Specific clinical question, e.g., "Determine audiologic candidacy and document aided speech recognition for ENT planning"]

Executive Summary

(Provide a concise synopsis for surgical and coverage decision-making. If any audit-critical metric is missing, explicitly document the reason.)

• Candidacy Impression: [candidate / borderline candidate / not a candidate today] for cochlear implantation; [ear(s) recommended: right / left / bilateral / to be determined] (State rationale based on documented findings.)
• Hearing Loss Summary: [Type], [severity range], [configuration], [symmetry/asymmetry].
• Amplification Status: [Appropriately fit and verified: yes / no / unclear]; [consistency of use with datalogging hours/day if available]; [perceived benefit/limitations].
• Best-Aided Recorded Open-Set Sentence Score: [Percent correct] at [presentation level dB] in [quiet / noise at SNR]; [device configuration]; [test name]. (If not obtained, document why.)
• Ear-Specific Aided Word Recognition: [Right ear: percent at dB, test] | [Left ear: percent at dB, test] (Include only if performed.)
• Next Steps: [ENT referral status], [imaging needs], [vaccination review], [aural rehab planning].

Records Reviewed

• [Prior audiograms with dates]
• [Hearing aid fitting/verification records with dates]
• [ENT/otology notes with dates]
• [Imaging summaries with dates]
• [Outside speech perception testing with dates]

(If no external records available, state: "No external records were available for review.")

History

Information Sources: [patient report / caregiver report / chart review / outside records]

Hearing Loss History: [Onset], [duration], [etiology if known], [progression pattern].

Otologic History: [Ear surgeries], [chronic otologic conditions], [vestibular symptoms], [tinnitus].

Amplification History: [Devices used], [years of use], [consistency], [perceived benefit and limitations].

Communication and Functional Impact: [Typical listening environments], [occupational/educational demands], [phone use], [safety concerns], [localization needs].

Rehab Readiness: [Motivation], [goals], [support system], [ability to attend mapping/therapy]. (Do not infer without explicit information.)

(For pediatric patients: [Developmental milestones], [IFSP/IEP/504 services], [therapy providers], [school placement].)

Current Amplification

Devices: [Manufacturer], [model], [style], [ear(s)], [coupling], [fitting prescription/formula].

Verification Status: [Real-ear verification completed today / previously documented with date / unavailable].

Datalogging: [Hours/day] (if available).

Testing Configuration(s):

• [Right aided only with left occluded/masked]
• [Left aided only with right occluded/masked]
• [Best-aided binaural]

(If hearing aids were not available or functioning, document why and note that definitive candidacy determination requires repeat testing with optimized amplification.)

Test Conditions and Methods

(This section is audit-critical for payer documentation.)

• Test Date: [MM/DD/YYYY]
• Booth/Room: [Type/standard]; soundfield speaker at [azimuth] and [distance].
• Calibration: [Calibration statement per local protocol].
• Speech Materials: [Recorded sentence materials and version]; [recorded word lists and version]. (Confirm recorded, not live voice.)
• Presentation Levels: [dB for speech stimuli]; if noise used: [noise level dB], [SNR dB], [noise type].
• Ear-Specific Aided Testing: [Masking and/or occlusion method used].
• Scoring Method: [Full/partial lists]; [stopping rules if applicable].

Audiologic Results

Otoscopy: [External canal status and any contraindications to ear-level devices].

Tympanometry: [Type/values]; acoustic reflexes [obtained / absent / not tested]. (Include only if performed.)

Pure-Tone Audiometry:

• Right Ear: [Air conduction thresholds by frequency], [bone conduction if obtained], [degree], [configuration], [reliability].
• Left Ear: [Air conduction thresholds by frequency], [bone conduction if obtained], [degree], [configuration], [reliability].
• Asymmetry: [Significant / not significant]; [specify frequencies and interaural differences if present].

Unaided Speech Recognition:

• Right Ear: SRT [dB HL]; word recognition [percent at dB HL, materials, masking].
• Left Ear: SRT [dB HL]; word recognition [percent at dB HL, materials, masking].

Interpretation (Unaided): [Brief summary of audiologic picture including type, degree, configuration, and expected functional impact].

Aided Speech Perception Testing

Aided Thresholds: [Warble tone thresholds by frequency and/or aided SII]; [statement on audibility adequacy for speech testing].

Aided Word Recognition (Monosyllabic, Recorded):

• Right Aided Only: [Percent correct] at [dB]; [test materials]; [masking/occlusion method].
• Left Aided Only: [Percent correct] at [dB]; [test materials]; [masking/occlusion method].

Aided Sentence Recognition (Recorded, Open-Set): (Critical measure for candidacy determination.)

• Best-Aided Condition: [Percent correct] at [dB in quiet / SNR in noise]; [test materials]; [device configuration]. (Best-aided score for candidacy.)
• Right Aided Only: [Percent correct] at [dB/SNR]; [test materials]. (Include only if performed.)
• Left Aided Only: [Percent correct] at [dB/SNR]; [test materials]. (Include only if performed.)

(If standardized recorded open-set sentence testing could not be completed, document reason and any alternative measures used. Note that payer criteria may require recorded open-set sentence testing for definitive determination.)

Patient-Reported Outcomes

• [Instrument name]: [Score] ([Date])
• Communication Goals: [Goals identified by patient/caregiver].

(For pediatric patients, include caregiver/teacher reports on listening behaviors and device use.)

Interpretation and Candidacy Impression

Unaided Summary: [Concise summary of hearing status by type, degree, configuration, and symmetry].

Amplification Adequacy: [Appropriately fit and verified / limitations noted / adequacy unclear]. (State verification status and any constraints impacting interpretation.)

Limited Benefit from Amplification: Recorded open-set sentence score in best-aided condition: [percent correct] at [dB], [quiet/SNR], [test name]. (This is the recorded, best-aided result used for candidacy determination.)

Ear-Specific Candidacy Impression: [Primary candidate ear] based on [severity, aided performance, asymmetry, patient goals]. [Contralateral ear considerations].

Additional Considerations: [Non-audiologic contributors to flag for further evaluation, if applicable]. (Do not diagnose outside scope.)

(Do not infer payer eligibility or medical/surgical clearance. ENT evaluation is required for medical clearance and surgical planning.)

Counseling Provided

• Expectations: [Outcomes in quiet vs noise, adaptation timeline, variability].
• Post-Operative Care: [Mapping schedule, aural rehabilitation importance].
• Alternatives Discussed: [Optimized hearing aids, assistive technology, communication strategies].
• Patient/Caregiver Response: [Understanding, goals, concerns expressed].

(For pediatric patients, include family goals and educational support coordination.)

Plan and Coordination

1. [ENT referral status and specific information provided from this evaluation].
2. [Pre-operative workup: imaging per ENT, vaccination review].
3. [Aural rehabilitation services recommended and timeline].
4. [Device counseling and next steps].
5. [If not a candidate today: optimization plan, repeat testing timeline, re-referral triggers].

Limitations and Attestation

Testing Limitations: [Hearing aid issues, patient fatigue, language barriers, nonstandard test substitutions, equipment constraints, or none].

Results are valid to the extent of patient cooperation and test conditions described.

Signature: [Audiologist name, credentials, license number] | Date/Time Signed: [MM/DD/YYYY HH:MM]

(If information for a section was not obtained or does not apply, omit that section. Exception: Test Conditions and Methods, Aided Sentence Recognition, and Candidacy Impression are audit-critical and must explicitly note if data are missing and why.)