Hearing Conservation Audiogram Review Note

Patient Name: [Patient full name]

DOB: [Date of birth]

Employee ID: [Employee identifier]

Date of Review: [Date of record review]

Reviewer: [Name, credentials, role]

Employer/Program: [Employer name or Hearing Conservation Program name]

Reason for Review: [Baseline review / Annual monitoring review / Retest review / STS follow-up / Termination review]

Audiogram Date(s): Baseline: [Date]; Current: [Date]; Retest: [Date if applicable]

Reason for Review and Context

[Brief statement of review purpose, hearing conservation program enrollment status, and any recent job or exposure control changes if known] (Write 2–3 sentences. If noise exposure data are not provided, state that the employee is listed as participating in the hearing conservation program without inferring specific exposure levels.)

Noise Exposure and Risk Factors

• Work role and noise sources: [Job title/role]; [Primary noise sources/processes] (If not assessed, document "Not assessed.")
• Hearing protection devices: [Type]; [Fit/training status]; [Use pattern: always / often / sometimes / rarely / unknown]; [Dual protection if applicable]
• Non-occupational noise: [Firearms / Music / Power tools / Motorsports / None / Not assessed]
• Ototoxic exposures/medications: [Solvents / Heavy metals / Ototoxic medications / None / Not assessed]
• Relevant ear/medical history: [Ear surgery / Chronic otitis / Prior diagnosed hearing loss / Vestibular history / None / Not assessed]

Current Symptoms

• Hearing difficulty: [Present / Absent / Not assessed]; [Context if provided]
• Tinnitus: [Present / Absent / Not assessed]; [Laterality: Right / Left / Bilateral]; [Onset/course if stated]
• Ear fullness/pressure: [Present / Absent / Not assessed]
• Otalgia: [Present / Absent / Not assessed]
• Otorrhea: [Present / Absent / Not assessed]
• Vertigo/dizziness: [Present / Absent / Not assessed]; [Associated neurologic symptoms if present]
• Work communication concerns: [Present / Absent / Not assessed]
• [Direct patient quote if relevant to onset, severity, or medicolegal significance]

(If symptoms suggest urgent pathology—sudden unilateral hearing loss, acute vertigo with neurologic symptoms, or severe pain with drainage—ensure explicit escalation in the Plan.)

Test Information and Validity

• Test type: [Baseline / Annual monitoring / Retest / Termination]
• Quiet period requirement: [Met / Not met / Unknown]; [Method: Noise avoidance / HPD use]
• Recent high noise exposure same day: [Yes / No / Unknown]
• Reliability: [Good / Fair / Poor]; [Rationale if fair/poor]
• Barriers affecting test quality: [Cerumen / Language barrier / Inconsistent responses / Illness / Equipment issues / None]
• Calibration/booth data: [Reviewed / Maintained separately]

Results Summary

[Audiogram attachment status] (State that the audiogram is attached or imported into the record.)

• Right ear thresholds (dB HL): 2 kHz: [value]; 3 kHz: [value]; 4 kHz: [value]; 2/3/4 kHz average: [value]; Additional frequencies if tested: 0.5 kHz: [value]; 1 kHz: [value]; 6 kHz: [value]; 8 kHz: [value]
• Left ear thresholds (dB HL): 2 kHz: [value]; 3 kHz: [value]; 4 kHz: [value]; 2/3/4 kHz average: [value]; Additional frequencies if tested: 0.5 kHz: [value]; 1 kHz: [value]; 6 kHz: [value]; 8 kHz: [value]
• Qualitative summary: [Brief configuration description by ear]
• Untested or no response frequencies: [Frequencies and impact on shift determination, or "None"]

Threshold Shift Determination

Reference Baseline: Right ear: [Date]; [Original / Revised]; Left ear: [Date]; [Original / Revised]

Comparison Audiogram: [Date of annual used for determination]; Retest: [Date if applicable]

Definition used: [OSHA STS (≥10 dB average at 2/3/4 kHz) / Other program-defined criteria]

Age correction: [Applied / Not applied]; [Table/source if applied]; [Applied to: Baseline / Current / Both]

Shift Calculations (dB):

• Right ear: 2 kHz: Baseline [dB] → Current [dB] = Δ[dB]; 3 kHz: Baseline [dB] → Current [dB] = Δ[dB]; 4 kHz: Baseline [dB] → Current [dB] = Δ[dB]; Average Δ: [dB]
• Left ear: 2 kHz: Baseline [dB] → Current [dB] = Δ[dB]; 3 kHz: Baseline [dB] → Current [dB] = Δ[dB]; 4 kHz: Baseline [dB] → Current [dB] = Δ[dB]; Average Δ: [dB]

STS Determination: [STS present / No STS]; [Laterality: Right / Left / Bilateral / N/A]; [Retest outcome: Confirmed / Resolved / Pending retest / N/A]; [Validity concerns affecting interpretation if any]

(If baseline unavailable: "Baseline audiogram unavailable—threshold shift determination cannot be completed. Request baseline audiogram." Etiologic impressions must be qualified; monitoring audiometry alone is not diagnostic for hearing loss type or etiology.)

Problem Audiogram Flags

[Document any findings warranting evaluation beyond routine monitoring, or "None identified"] (Include if present: marked asymmetry between ears with description; unilateral or asymmetric tinnitus; rapid progression inconsistent with expected patterns; low-frequency or conductive-appearing pattern noting bone conduction needed to confirm; poor reliability or suspected non-organic responses; otologic/neurologic symptoms suggesting pathology. Any flagged item must have corresponding action in Plan.)

Assessment

• Hearing status: Right ear: [Normal / High-frequency loss / Other description]; Left ear: [Normal / High-frequency loss / Other description]
• Threshold shift status: [No STS / STS present: Right / Left / Bilateral]; [Confirmed / Resolved / Pending confirmation]
• Validity considerations: [None / Factors affecting interpretation]

Counseling Provided

[Document counseling actually provided] (Include as applicable: explanation of results in plain language; HPD counseling including fit/insertion technique and when to use; noise avoidance strategies; explanation of threshold shift meaning; warning signs requiring medical evaluation. If counseling not performed due to remote record review, state: "Counseling not performed—recommend employer/clinic provide per program protocol.")

Plan

• Retest: [Indicated within 30 days / Not indicated]; [Responsible party if indicated]
• HPD actions: [Refit / Retraining / Consider greater attenuation or dual protection / No change indicated]; [Note if contingent on exposure data]
• Referrals: [Diagnostic audiology with bone conduction / ENT evaluation / Occupational medicine / None]; [Indication]
• Employee notification: [Written notification completed / Pending / Unknown to reviewer] (OSHA requires written notification within 21 days of STS determination.)
• Baseline revision: [Recommend revision / Do not revise / Defer pending confirmation]; [Ear(s)]; [Rationale]
• Follow-up: [Next annual monitoring date / Earlier follow-up: date and indication]

Signature

Electronically signed by: [Name, credentials, date/time]

[Supervision documentation if applicable] (If technician performed initial comparison and clinician reviewed, document supervision chain and reviewer's conclusion.)