Hearing Screening Report

Date/Time of Screening: [Date and time]
Location/Setting: [clinic / school / newborn nursery / NICU / occupational health / other]
Screener: [Name, credentials]
Patient Name: [Full name]
DOB: [Date of birth]
Age: [Age]
Sex: [Sex]
MRN: [Medical record number / Unknown]
Parent/Guardian Present: [Yes / No] (Include for pediatric encounters only; omit line if not applicable.)

(This is a screening encounter. Use only "Pass," "Did Not Pass," or "Could Not Test/Incomplete" for outcomes—never "normal hearing" or "hearing loss." Do not infer degree or type of hearing loss. Omit section headers if that component was not performed, except Ear Inspection which should note "Not performed" with reason. For missing information use: "Not obtained," "Not performed," or "Unknown." Unilateral Did Not Pass or Could Not Test results require an explicit follow-up plan.)

Reason for Screening

[Reason for screening: routine/preventive per age-based schedule, targeted due to concern/exposure/monitoring, or follow-up rescreen] (Include prior screening history if known: date, method, result, location.)

Relevant History

• Patient/caregiver concerns: [Hearing difficulty, inattentiveness, speech/language delay, tinnitus, ear pain, drainage / None / Not obtained / Unknown]
• Otologic history: [Recurrent otitis media, tubes, ear surgery, known perforation / None / Not obtained / Unknown]
• Relevant exposures: [Noise exposure, ototoxic medications, meningitis, head trauma / None / Not obtained / Unknown]
• Developmental/behavioral factors affecting test reliability: [Factors / None / Not obtained / Unknown]
• Newborn/infant risk factors: [NICU >5 days, congenital infections, craniofacial anomalies, family history of childhood hearing difference / None / Not applicable] (Include for newborn/infant screenings only.)

Pre-Screening Conditions

• Environment: [Quiet room / Background noise present; describe limitations]
• Equipment: [Device and transducer type]
• Patient state/cooperation: [Asleep / calm / attentive / crying / fatigued / unable to condition]
• Calibration/biologic check: [Completed / Not performed / Unknown] (Include if tracked per program protocol.)

Ear Inspection

• Right Ear:
  • Canal patency: [Clear / partially occluded / occluded]
  • Cerumen: [None / non-occlusive / impacted/obstructing]
  • Drainage or foreign body: [None / present]
  • Otoscopy: [Not performed] or [Performed: TM appearance - normal / erythematous / bulging / retracted / perforation / PE tube present; Middle ear effusion suspected - Yes / No / Uncertain]
• Left Ear:
  • Canal patency: [Clear / partially occluded / occluded]
  • Cerumen: [None / non-occlusive / impacted/obstructing]
  • Drainage or foreign body: [None / present]
  • Otoscopy: [Not performed] or [Performed: TM appearance - normal / erythematous / bulging / retracted / perforation / PE tube present; Middle ear effusion suspected - Yes / No / Uncertain]

(If ear inspection not performed for either ear, document "Not performed" with reason: equipment unavailable, patient intolerance, or other.)

Screening Method(s) and Results

(Include only subsections for methods actually performed. For each method, document protocol parameters, ear-specific outcomes, immediate rescreen if performed, and factors affecting validity.)

Pure Tone Audiometry (Screening)

• Protocol: [Frequencies (Hz)] at [Screening level (dB HL)] using [Transducer type]; [Response mode/conditioning method]
• Right Ear: [Pass / Did Not Pass / Could Not Test/Incomplete]
  • Validity factors: [None / poor cooperation / environmental noise / inability to condition / other]
  • Immediate rescreen: [Not performed / Performed - outcome: Pass / Did Not Pass / Could Not Test/Incomplete]
• Left Ear: [Pass / Did Not Pass / Could Not Test/Incomplete]
  • Validity factors: [None / poor cooperation / environmental noise / inability to condition / other]
  • Immediate rescreen: [Not performed / Performed - outcome: Pass / Did Not Pass / Could Not Test/Incomplete]

Otoacoustic Emissions (OAE)

• Protocol: [TEOAE / DPOAE]; [Stimulus/parameters if available]
• Right Ear: [Pass / Did Not Pass / Could Not Test/Incomplete]
  • Validity factors: [None / noise / poor seal / movement / crying / other]
  • Immediate rescreen: [Not performed / Performed - outcome: Pass / Did Not Pass / Could Not Test/Incomplete]
• Left Ear: [Pass / Did Not Pass / Could Not Test/Incomplete]
  • Validity factors: [None / noise / poor seal / movement / crying / other]
  • Immediate rescreen: [Not performed / Performed - outcome: Pass / Did Not Pass / Could Not Test/Incomplete]

Automated Auditory Brainstem Response (AABR)

• Protocol: [Device/algorithm]; [Stimulus type/level if available]
• Right Ear: [Pass / Did Not Pass / Could Not Test/Incomplete]
  • Validity factors: [None / noise / poor electrode contact / crying / movement / other]
  • Immediate rescreen: [Not performed / Performed - outcome: Pass / Did Not Pass / Could Not Test/Incomplete]
• Left Ear: [Pass / Did Not Pass / Could Not Test/Incomplete]
  • Validity factors: [None / noise / poor electrode contact / crying / movement / other]
  • Immediate rescreen: [Not performed / Performed - outcome: Pass / Did Not Pass / Could Not Test/Incomplete]

Tympanometry

• Probe tone frequency: [226 Hz / 1000 Hz]
• Right Ear:
  • Peak pressure: [Value] daPa; Static compliance: [Value] ml; Ear canal volume: [Value] ml; Tympanometric width: [Value] daPa
  • Interpretation: [Normal / suggests middle ear effusion / suggests negative pressure / flat with large volume / other]
  • Validity factors: [None / poor seal / movement / crying / other]
• Left Ear:
  • Peak pressure: [Value] daPa; Static compliance: [Value] ml; Ear canal volume: [Value] ml; Tympanometric width: [Value] daPa
  • Interpretation: [Normal / suggests middle ear effusion / suggests negative pressure / flat with large volume / other]
  • Validity factors: [None / poor seal / movement / crying / other]

Results Summary

(Include only columns for methods performed; remove unused columns.)

Ear	Ear Inspection	Pure Tone	OAE	AABR	Tympanometry	Overall Outcome
Right	[Summary / Not performed]	[Pass / Did Not Pass / Not Performed / Could Not Test]	[Pass / Did Not Pass / Not Performed / Could Not Test]	[Pass / Did Not Pass / Not Performed / Could Not Test]	[Pass / Did Not Pass / Not Performed / Could Not Test]	[Pass / Did Not Pass / Could Not Test]
Left	[Summary / Not performed]	[Pass / Did Not Pass / Not Performed / Could Not Test]	[Pass / Did Not Pass / Not Performed / Could Not Test]	[Pass / Did Not Pass / Not Performed / Could Not Test]	[Pass / Did Not Pass / Not Performed / Could Not Test]	[Pass / Did Not Pass / Could Not Test]

Overall Outcome Statement: [Pass bilaterally / Did Not Pass (Right ear) / Did Not Pass (Left ear) / Did Not Pass (bilateral) / Incomplete—could not condition to task]

Interpretation

[Brief synthesis of findings using screening-appropriate language] (Note whether findings suggest possible transient conductive contributors such as cerumen or middle ear dysfunction versus concern for persistent hearing difference warranting diagnostic evaluation. State limitations: poor cooperation, incomplete data, environmental noise, probe fit issues, or other.)

Screening does not establish diagnostic hearing status.

Plan

• If Pass with no concerns: [Routine preventive follow-up interval per schedule]; [Hearing health counseling provided: noise protection, otitis media monitoring, communication strategies as applicable]
• If Pass but concern/risk persists: Normal screening does not negate concern; [Audiology / ENT / further evaluation referral] within [Timeframe]
• If Did Not Pass: Immediate rescreen [performed / not performed]; [Audiology referral placed within timeframe] or [Timed rescreen in 6–8 weeks after treatment of suspected transient cause with rationale]
• If unilateral Did Not Pass or Could Not Test: [Explicit follow-up plan: audiology referral preferred] within [Timeframe]
• If cerumen prevented screening: [Cerumen removal performed / Referred for removal]; Repeat screening planned [Timeframe]
• For newborn/infant Did Not Pass: [Outpatient rescreen / Diagnostic audiology referral] consistent with EHDI 1-3-6 timeline; [Referrals placed]; [Caregiver instructions provided]
• Referrals placed: [Audiology / ENT / Primary care / Early Intervention / None]
• Return precautions: [Worsening pain, fever, drainage, sudden hearing change]

Communication and Education

Results discussed with [patient / parent / guardian]. Questions addressed. [Written materials provided / No written materials provided]. [Importance of follow-up reinforced if referral made]. Return precautions reviewed.

Signature

Screener Signature: [Name, credentials]
Date/Time Signed: [Date and time]