Newborn Hearing Screening Report

Infant Name: [Infant full name]

MRN: [Medical record number]

Date of Birth: [DOB]

Sex: [Sex]

Facility: [Hospital/Clinic name and location]

Care Setting: [Well-Baby Nursery / NICU / Outpatient]

Parent/Guardian Name(s): [Parent/Guardian name(s)] (Verify spelling; if unavailable, state "Not available" and note who will obtain)

Contact Phone: [Primary phone number] (Verify accuracy; if unavailable, state "Not available" and note who will obtain)

Primary Care Provider: [PCP name and practice / Not yet selected]

Screening Date/Time: [Date and time of encounter]

Screener Name/Credentials: [Name, credentials]

Screening Protocol

• Modality: [OAE / AABR / Two-stage OAE→AABR]
• Protocol: [Well-baby / NICU]
• Screening Indication: [Initial screen / Repeat inpatient screen / Outpatient rescreen / Post-transfer screen]
• Screen Performed: [Yes / No]
• If No, Reason: [Parent declined / Medically unstable / Anatomic contraindication / Transferred before screening / Equipment unavailable / Other] (Include only if screen not performed)
• Follow-up Pathway if Not Screened: [Specific next step, location, responsible party, timeframe] (Include only if screen not performed)
• Infant State: [Sleeping / Quiet alert / Drowsy / Crying / Excessive movement] (Include only if it affected test validity)

Screening Results

(Document ear-specific outcomes for each screening session. Repeat the session block for each session performed during this hospitalization.)

Session [Number]

• Date/Time: [Session date and time]
• Modality: [OAE / AABR] (Include if different from protocol or clarifies two-stage approach)
• Right Ear: [Pass / Did Not Pass / Could Not Test / Not Performed]
• Right Ear Reason: [Infant state / Equipment issue / Ear canal anomaly / Debris or fluid / Other] (Include only if Could Not Test or Not Performed)
• Left Ear: [Pass / Did Not Pass / Could Not Test / Not Performed]
• Left Ear Reason: [Infant state / Equipment issue / Ear canal anomaly / Debris or fluid / Other] (Include only if Could Not Test or Not Performed)
• Technical Notes: [Brief notes] (Include only if clinically relevant)

Final Screening Outcome: [Pass / Did Not Pass / Incomplete]

• If Did Not Pass, ear(s): [Right / Left / Both] (Include only if Did Not Pass)
• If Incomplete, information needed: [Specify what remains] (Include only if Incomplete)

(Pass requires both ears to pass in the same session. If any ear result is missing or screening not completed, select Incomplete. Do not infer Pass from incomplete data.)

Risk Indicators

Risk Indicators Present: [Yes / No / Unknown]

If Unknown, reason: [Incomplete prenatal records / Transfer without records / Other] (Include only if Unknown)

If Yes, identified risk factors and follow-up timing:

• [Risk factor] → [Recommended follow-up timeframe] (Examples: CMV → evaluation by 9 months with ongoing monitoring; ECMO → no later than 3 months after occurrence; family history of childhood hearing loss → by 9 months)

(Caregiver concern about hearing or speech-language at any time warrants immediate referral regardless of other timing.)

Interpretation

[Standardized 2–3 sentence interpretation stating the Final Screening Outcome clearly] (Use "typical hearing" rather than "normal hearing." State that newborn hearing screening is not diagnostic and may not detect all types or degrees of hearing difference, including mild or frequency-specific loss. If Did Not Pass, acknowledge transient factors may contribute but emphasize timely follow-up is essential. Do not provide false reassurance for Pass results in infants with risk indicators.)

Counseling Provided

• Counseling Date/Time: [Date and time]
• Recipient(s): [Parent/guardian names and relationship]
• Language/Interpreter: [Language and interpreter service if used / N/A]
• Topics Discussed: [Meaning of results / Importance of follow-up / Developmental milestones to monitor / When to seek evaluation for hearing concerns] (List topics that were discussed)
• Written Materials Provided: [Yes / No] (If yes, specify title and language)

Follow-Up Plan

(Select the pathway matching the Final Screening Outcome)

Pass with No Risk Indicators: Screening complete. Continue routine developmental surveillance in the medical home. Return precautions: refer promptly for audiologic evaluation if caregiver has concerns about hearing or speech-language, or if milestones are not met.

Pass with Risk Indicators:

• Required audiologic monitoring schedule: [Schedule based on identified risk factors]
• Audiology appointment: [Scheduled date/time/location/phone / Referral placed / Family instructed to schedule]
• Responsible party: [Name/role]

Did Not Pass:

• Inpatient next step: [Repeat screen planned with date/time / Proceed to diagnostic referral] (Include only if still inpatient)
• Outpatient follow-up: [Appointment date/time] at [Clinic name, address, phone]
• Contingency if missed: [Plan and responsible party for rescheduling]

Diagnostic audiologic evaluation should be completed by age 3 months per EHDI guidelines.

Incomplete / Not Screened:

• Reason: [Specify reason]
• Plan to complete: [Action, location, timeframe, responsible party]
• Family notified: [Yes / No] (If no, specify plan to contact)

Communication

• Results provided to family: [Yes / No] — Date: [Date] (If no, specify plan and responsible party)
• Results communicated to PCP/medical home: [Yes / No] — Date: [Date] — Method: [EMR message / Fax / Phone / Other] (If no, specify plan and responsible party)
• Results submitted to state EHDI system: [Yes / No / Pending] — Date: [Date] (If pending, specify responsible party)

Signature

Screener Signature/Credentials/Date: [Signature block]