Hearing Aid Fitting/Dispensing Procedure Note

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Date of Service: [Date and time of service]

Clinician: [Clinician name, credentials]

Location: [Clinic/site]

Reason for Visit

[Visit purpose: initial fitting / refit / exchange / loss-and-damage replacement] for [right / left / binaural / CROS / BiCROS]. Programming based on audiogram dated [audiogram date]. (Format as 1–3 sentences summarizing the purpose of today's encounter.)

Pre-Fitting Assessment

[Interval history since audiologic evaluation] (Include only if applicable: changes in hearing, tinnitus, otalgia, dizziness, interim ENT care. Omit if none.)

• Otoscopy – Right: [Canal status], [cerumen status], [TM status], [appropriate to proceed: yes / no with rationale]
• Otoscopy – Left: [Canal status], [cerumen status], [TM status], [appropriate to proceed: yes / no with rationale]

[Medical red flag findings and management] (If red flags identified, document findings, counseling provided, referrals placed, and whether fitting proceeded with rationale. If otoscopy or screening was not performed, document reason. Omit this paragraph if no red flags and screening completed.)

Devices Dispensed

	Right	Left
Manufacturer & Model	[Manufacturer, model]	[Manufacturer, model]
Style	[RIC / BTE / ITE / CIC / other]	[RIC / BTE / ITE / CIC / other]
Color	[Color]	[Color]
Serial Number	[Serial number]	[Serial number]
Receiver Length & Power	[Length, power level / N/A]	[Length, power level / N/A]
Coupling	[Dome type/size or custom mold material & vent]	[Dome type/size or custom mold material & vent]
Power Source	[Battery size / rechargeable]	[Battery size / rechargeable]
Warranty Start Date	[Date]	[Date]
Trial Period Start Date	[Date / N/A]	[Date / N/A]

(For unilateral fittings, enter "Not dispensed" for contralateral side. Serial numbers must not be left blank—use "Unable to obtain" with reason only if truly unavailable.)

Accessories Dispensed: [Accessories with serial numbers if tracked] (Omit if none dispensed.)

Quality Control

• Listening Check: [performed / not performed] – [Findings] (If not performed, document reason.)
• Electroacoustic/Test-Box Analysis: [performed / not performed] – [met manufacturer specs: yes / no] (If not performed, document reason and plan.)

Programming Parameters

• Prescriptive Target: [NAL-NL2 / DSL v5 / other]
• Adaptation/Acclimatization Level: [Level/percentage] (For new users; omit if experienced user.)
• Deviations from Target: [Adjustments with clinical rationale] (Omit if none.)
• Key Settings: Feedback management [enabled / run / not enabled]; frequency lowering [enabled with settings / not enabled]; programs [list with purposes]; data logging [reset / not reset]; user controls [volume and program button configuration]; connectivity [phone pairing, app, streaming status] (Include only clinically relevant settings; omit defaults.)

Verification

Real-Ear Measurement: [performed / not performed]

• If performed: Stimuli [type] at [input levels]. Target algorithm [algorithm]. Targets [met / within tolerance / not met] for [frequency regions]. Adjustments: [changes made]. MPO verified [within UCLs / adjusted / not completed with reason].
• If not performed: Reason [patient intolerance / equipment unavailable / time constraints / other]. Alternative verification: [aided sound-field / functional checks / subjective balancing]. Plan to complete: [timing/method].

Feature-Specific Verification: [Telecoil / directional microphones / CROS routing / frequency lowering] – [method and results] (Include only if performed.)

(Do not imply verification occurred based solely on first-fit software completion.)

Patient Response

[Patient-reported sound quality and comfort impressions] (Use direct quotes when helpful, e.g., "sounds tinny," "own voice is boomy.")

Functional Impressions: [Response in quiet], [response with background noise]

Outcome Measures: [Instrument name and score] (If deferred, note timing for administration. Omit if not applicable.)

Orientation & Counseling

Topics Reviewed: [Insertion/removal / wearing schedule / acclimatization / volume and program controls / telephone and streaming / charging or battery replacement / cleaning and wax guards / moisture precautions / troubleshooting / stop-use warnings]. Written materials [provided / not provided].

Teach-Back Observed:

• Insertion/removal: [competent / needs reinforcement]
• Power on/off or charger use: [competent / needs reinforcement]
• Battery change: [competent / needs reinforcement / N/A]
• Basic troubleshooting: [competent / needs reinforcement]

Demonstrated by: [Patient alone / with caregiver assistance – name/relationship]

Handling Barriers: [Dexterity / vision / cognition concerns and accommodations provided] (Omit if none.)

Plan

Follow-up: [Timing] for [objectives: physical fit check / data logging review / REM completion / programming adjustments / outcome measures / aural rehabilitation]

Return Precautions: Contact clinic for pain, drainage, sudden hearing change, or device stuck in ear.

Referrals/Communications: [Referrals placed and communication to referring providers] (Omit if none.)

Clinician Signature: [Name, credentials]    Date/Time: [Date and time signed]