Hearing Assistive Technology Evaluation Note

Encounter Date: [Date of service]

Location/Setting: [Clinic / school / home visit / community site]

Clinician: [Clinician name and credentials]

Patient: [Patient identifiers per local policy]

Referral Source: [Referring clinician or agency / Self-referred / Not applicable]

Participants Present: [Patient and any caregivers, communication partners, teachers, or interpreters with roles]

Primary Communication Mode: [Spoken language / ASL / captioning / interpreter / other]

Hearing Devices Present: [Current hearing aids and/or cochlear implant processors with make/model; accessories brought; patient phone/tablet model and OS if relevant to streaming]

Reason for Visit

[Listening problem(s) and primary environments where difficulty occurs; visit type; functional impact] (1–3 sentences. State whether this is an initial HAT evaluation, trial follow-up/validation, troubleshooting/optimization, or training-only session. Include functional impact such as participation restrictions, safety concerns, or work/school performance issues. A brief direct patient quote may be included.)

Relevant History

• Audiologic data reviewed: [Date, type of testing, and findings pertinent to HAT candidacy] (Cite source if from prior records.)
• Current hearing device use: [Typical wear time, programs, and known challenges with noise, distance, or connectivity]
• Prior assistive technology: [Devices tried, settings, outcomes, and reasons for discontinuation if relevant]
• Priority listening environments: [Target situations and acoustic challenges such as distance, multi-talker noise, reverberation, masks, soft speech]
• Communication partners: [Frequent partners, group size, classroom/meeting considerations, multi-user needs]
• Safety/alerting needs: [Alarms, doorbell, phone, emergency awareness]
• User factors: [Vision, dexterity, cognition, technology comfort, smartphone compatibility, caregiver support]

(If any domain was not assessed, note "Not assessed" with brief reason rather than omitting silently.)

Functional Goals

(Document 2–5 prioritized patient-centered goals in decreasing order of importance. For each goal, specify situation/context, desired functional outcome, and current baseline ability. Use patient language when helpful and translate into measurable targets when possible.)

• Goal 1: [Situation/context]; [Desired functional outcome]; [Current baseline ability]
• Goal 2: [Situation/context]; [Desired functional outcome]; [Current baseline ability]
• Goal 3: [Situation/context]; [Desired functional outcome]; [Current baseline ability]

(Add or remove goals as appropriate.)

Baseline Status

(Include this section when any comparative benefit claim will be made.)

• Baseline condition: [Unaided / hearing aids only / CI only / specific program]
• Objective measures: [Test name, level/SNR, score; specify if performed today vs. prior with source and date]
• Functional observations: [Clinician-observed behaviors in relevant listening conditions]
• Patient-reported ratings: [Structured ratings for each goal or standardized questionnaire scores]

Device Trial

(Create a separate subsection for each device/accessory evaluated. Note any limitations in standardizing trial conditions.)

[Device 1: Category and make/model]

• Accessory/Configuration: [Accessory type or configuration details]
• Coupling Pathway: [Direct wireless to HAs / streaming to CI processor / Bluetooth to phone then to devices / neckloop to telecoil / other]
• Microphone Mode: [Omni / directional / beamforming / table / presenter / other] (If applicable.)
• Trial Conditions: [Talker-listener distance and orientation; microphone placement; noise type and relative level; room description]
• Verification/Checks: [Functional checks, pairing status, battery/charge, latency, level matching]
• Troubleshooting: [Issues encountered and resolution or remaining issues] (If applicable.)

[Device 2: Category and make/model]

(Repeat elements above for additional devices as applicable.)

Benefit Assessment

(Report outcomes comparing baseline to HAT-aided condition. Explicitly state baseline condition and comparison method.)

• Objective outcomes: [Test name and conditions] — Baseline: [score]; HAT-aided: [score]; Difference: [value]
• Patient-reported benefit: [Structured ratings by goal and/or standardized questionnaire with scores and scale]
• Adverse perceptions: [Distortion / latency / reduced environmental awareness / discomfort / none reported]
• Clinician observations: [Functional abilities observed such as following TV dialog, identifying talker with remote mic]
• Scope and tradeoffs: [Scenarios where benefit was or was not demonstrated; tradeoffs observed]

Training Provided

• Topics covered: [On/off and charging; pairing/re-pairing; microphone placement; program switching and volume; TV streamer setup; cleaning/storage; troubleshooting; situational awareness and safe listening levels]
• Competency verification: [Patient and/or caregiver demonstrated tasks: independently / with minimal cueing / with moderate cueing / unable]
• Materials provided: [Written instructions / manufacturer guides / video links / checklists]
• Training deferred: [Reason] (If applicable.)

Assessment

[Problem-oriented narrative addressing HAT candidacy, benefit evidence, barriers/risks, and prognosis] (Address whether patient is appropriate for evaluated HAT and why; link benefit claims to documented outcomes; note barriers such as handling challenges, inconsistent use, or phone incompatibility; state prognosis with proper setup or training. If multiple devices trialed, state preferred option and rationale. Do not claim benefit without linking to documented evidence.)

Recommendations and Plan

• Recommended technology: [Device category and make/model]; [Intended use cases tied to goals]; [Key settings/program recommendations]
• Trial/procurement: [Loaner issued / purchase planned]; [Trial duration and use schedule]; [Data patient should track]
• Follow-up: [Timeframe and purpose]; [Planned outcome measures for next visit]
• Referrals/coordination: [ENT / speech-language pathology / school team / vocational rehabilitation] (Include purpose if applicable.)
• Counseling on access options: [Community loop systems, venue accessibility, captioning resources] (If relevant to patient goals.)