Ototoxicity Monitoring Report

Patient: [Full name]; DOB: [DOB]; MRN: [MRN]; Sex: [recorded sex]

Date of Service: [Date and time]

Location: [sound booth / bedside / other] [Test environment constraints if any]

Ordering Provider: [Name and service] (If unavailable, state: "Order/referral: not found in chart at time of report")

Attending Oncologist: [Name]

Monitoring Timepoint: [Baseline / Pre-cycle #__ / Mid-treatment / End-of-treatment / Post-treatment follow-up (__ months) / Symptom-triggered]

Ototoxic Agent(s): [Verified agent(s)] (If unknown, state: "not available in chart at time of report")

Executive Summary

Overall Status: [No significant ototoxic change / Significant ototoxic change detected / Indeterminate (see limitations)]

Comparison Reference: Baseline: [date]; Most recent prior: [date] (If no baseline exists, state: "Today's test serves as initial baseline reference; baseline-relative change cannot yet be computed.")

Ear(s) Affected: [right / left / bilateral / N/A]

Key Findings: [Largest threshold shift(s) with specific frequencies and magnitude in dB; whether confirmed by immediate retest; any new "no response" findings with output limits]

Interval Symptoms: Hearing change: [new / worse / unchanged / denied] | Tinnitus: [new / worse / unchanged / denied] | Aural fullness: [new / worse / unchanged / denied] | Dizziness/imbalance: [new / worse / unchanged / denied]

Clinical Significance: [One sentence describing functional impact, e.g., changes limited to extended high frequencies vs speech frequencies affected]

Recommended Action: [Retest timing if indicated; ongoing monitoring cadence; referrals warranted]

Communication Status: [Oncology notified: yes / no / pending]; [method: EHR / phone / in-person]; [date/time] (If pending, state reason.)

Indication and Clinical Context

[Brief narrative (2–4 sentences): indication for serial monitoring; trigger for today's visit (scheduled protocol vs symptom-triggered vs provider request); treatment context including ototoxic agent(s), treatment start date, most recent dose date, and cycle number if applicable; relevant risk modifiers (renal dysfunction, prior hearing loss, noise exposure) only if documented] (If treatment details unavailable, state "not available in chart at time of report" rather than inferring.)

Interval History

• Hearing change: [better / worse / unchanged / denied / not assessed]; [laterality]; [onset timeframe]
• Tinnitus: [present / absent / denied / not assessed]; [new / prior / worsened / unchanged]; [laterality]; [characterization if clarifying]
• Aural fullness or ear pain: [present / absent / denied / not assessed]; [laterality]
• Dizziness/imbalance/vertigo: [present / absent / denied / not assessed]; [falls or safety concerns if reported]
• Notable noise exposure since last test: [yes / no / not assessed]; [details if yes]
• Intercurrent ear disease: [URI / otitis / cerumen / other / none / not assessed]; [details if present]

Audiologic Methods

• Test environment: [sound booth / bedside / other]; [constraints affecting thresholds if any]
• Transducers: [insert earphones / supra-aural headphones / circumaural headphones]
• Extended high-frequency audiometry: [yes / no] (If no, state reason.)
• Response reliability: [good / fair / poor]; [brief explanation if not good]
• Tests completed:
  • Otoscopy
  • Tympanometry: [probe tone]
  • Pure-tone air conduction: [frequency range tested]
  • Bone conduction: [performed / not performed]; [frequencies if performed]
  • Extended high-frequency audiometry: [performed / not performed]; [frequency range if performed]
  • Speech testing: [SRT; word recognition with presentation level and list type] (If deferred, state reason.)
  • Otoacoustic emissions: [performed / not performed]; [type if performed]
  • Auditory brainstem response: [performed / not performed]
• Protocol deviations: [none / specify with reason]

Findings

Otoscopy and Middle Ear

Otoscopy: [Canal status; TM visualization; abnormalities] (Note impact on threshold interpretation if cerumen or middle ear findings present.)

Tympanometry: Right: [type and interpretation]; Left: [type and interpretation]; [comment on conductive component: possible / unlikely]

Pure-Tone Audiometry

Conventional frequencies (0.25–8 kHz):

[Threshold table by frequency for right and left ears] (Note any "no response" with output limits.)

Extended high frequencies (9–16+ kHz):

[Threshold table if obtained] (Note any "no response" with output limits. If not tested, state reason.)

Speech Testing

SRT: Right [dB HL], Left [dB HL]; Word recognition: Right [% at dB HL], Left [% at dB HL] (If not performed, state reason.)

Objective Measures

(Include only if OAE or ABR performed.)

[OAE/ABR results: present / reduced / absent with brief interpretation by ear; note these are adjunctive to behavioral thresholds]

Serial Comparison and Change Determination

Comparison Reference: Baseline: [date]; Most recent prior: [date] (If baseline unavailable, state: "Baseline unavailable; cannot apply baseline-relative shift criteria. Today's thresholds serve as initial reference.")

Significant Change Determination: Criterion: [institutional criterion set used]; Meets ototoxic change criteria: [YES / NO]

• (If YES: list exact frequencies, ear(s), shift magnitude in dB, and whether confirmed by immediate retest.)
• (If NO but trend exists: describe as "early trend" or "small change below criterion" without definitive labeling.)

[Mini-table for significant shifts: Frequency → Baseline threshold → Current threshold → Delta] (Include only for frequencies meeting criteria.)

Configuration Summary: [1–2 sentences: whether changes are confined to extended high frequencies vs encroaching on speech frequencies; any asymmetry warranting medical follow-up]

CTCAE Grading: (Include only if clinical trial or oncology requests standardized grading.)

[CTCAE v__ Hearing impaired Grade __ (basis); Tinnitus Grade __; Vertigo Grade __] (If data insufficient, state: "CTCAE grade not assigned—insufficient data.")

Assessment

[Primary impression using guarded causal language: findings consistent with / concerning for / with temporal association to ototoxic exposure; or no significant change; or interpretation limited by confounders]

Limitations: [missing baseline / poor reliability / ambient noise / middle ear pathology / incomplete frequency coverage / inability to test extended high frequencies / none] (List all that apply.)

Plan

• Monitoring: [Recommended next audiology date/timeframe] (If stable, continue protocol cadence; if significant shift, confirm promptly and increase monitoring frequency; if symptomatic, expedite.)
• Referrals: [ENT/otology / vestibular evaluation / audiologic rehabilitation / tinnitus management] (Include only if indicated, with brief rationale.)
• Patient Counseling Documented: [Counseling provided: symptom reporting instructions, noise avoidance during therapy, follow-up plan] (If counseling could not occur, document why and who received information.)

Communication and Disposition

Notification: [Who notified (name/service)]; [when]; [method: EHR message / phone / in-person]; [one-line summary of findings and recommended actions communicated]

(For significant/confirmed ototoxic change, state: "Time-critical notification completed" or "Pending—[reason].")

Patient Disposition: [Returned to infusion / clinic / inpatient unit; immediate instructions provided]

Signature

Audiologist: [Name, credentials]

Date/Time Signed: [Date and time]

Attachments

• Current audiogram: [attached / reference location in EHR]
• Baseline audiogram: [attached / reference location in EHR]
• Most recent prior audiogram or overlay comparison: [attached / reference location in EHR]