Pediatric Diagnostic ABR/ASSR Report

Report Title: Pediatric Diagnostic ABR/ASSR Report

Patient: [Full name], DOB: [Date of birth], Sex: [Sex], MRN: [Medical record number] (If any identifier is unavailable, enter "Not available" rather than leaving blank.)

Date of Service: [Date], [Start time–End time or total test duration]

Location: [Clinic / OR / NICU / Bedside / Other]

Referring Provider: [Name and credentials]

Ordering Diagnosis/Indication: [From order]

Testing Audiologist: [Name, credentials]

Interpreting Audiologist: [Name, credentials] (Include if different from tester; otherwise omit this line.)

Reason for Test

[Primary reason for evaluation and clinical questions to be answered] (One to three sentences stating the key indication(s) such as ear-specific threshold estimation, type of loss determination, neural integrity/ANSD assessment, and cross-check with other measures. If reason is unclear from the order, document: "Reason not specified on order; evaluation performed to estimate hearing thresholds.")

Relevant History

• Perinatal/Medical: [Gestational age and corrected age if premature, NICU stay and relevant exposures, craniofacial anomalies, syndromic concerns, meningitis/CMV history] (Only include items explicitly documented.)
• Hearing History: [Newborn hearing screen method, dates, ear-specific outcomes, caregiver concerns and observed auditory behaviors, otitis media history, PE tubes, ear surgeries]
• Prior Audiology: [Behavioral audiometry with reliability, tympanometry, OAEs, prior ABR/ASSR with dates and summary]
• Amplification/Intervention: [Current devices, early intervention enrollment status]

(If history limited due to time constraints, document: "Targeted history obtained; see chart for full medical history.")

Test Setting and Patient State

• Setting: [Sound booth / Bedside / OR / NICU / Other]
• Patient State: [Natural sleep / Quiet sleep / Awake / Restless / Sedated / Under general anesthesia]
• Recording Factors: [Movement/myogenic artifact, electrical interference, excessive ambient noise, time constraints, medical instability] (If none, document "No significant recording issues observed.")
• Sedation/Anesthesia: [Yes / No]. (If No, state whether testing completed during natural sleep or awake state. If Yes, specify [Moderate sedation / Deep sedation / General anesthesia] and document: "Sedation details per anesthesia record." Note any audiology-relevant impacts such as oxygen flow noise, time limitations, or incomplete testing.)

Cross-Check Measures

Otoscopy

• Right Ear: [Canal status, TM appearance if visualized, PE tube status]
• Left Ear: [Canal status, TM appearance if visualized, PE tube status]

(If not performed, state reason.)

Acoustic Immittance

Ear	Probe Tone	ECV	Peak Pressure	Compliance/Admittance	Tymp Type	Interpretation
Right	[1000 Hz / 226 Hz]	[Value]	[Value]	[Value]	[A / B / C / As / Ad]	[Interpretation]
Left	[1000 Hz / 226 Hz]	[Value]	[Value]	[Value]	[A / B / C / As / Ad]	[Interpretation]

Acoustic Reflexes: [Ipsilateral/Contralateral findings by frequency per ear, present/absent/elevated, stimulus levels, reliability concerns] (If not performed, state reason.)

Otoacoustic Emissions

Type: [TEOAE / DPOAE], Frequencies: [Frequencies tested], Pass Criteria: [Criteria used]

• Right Ear: [Present/Absent by frequency, noise floor issues, probe fit limitations, middle-ear status limitations]
• Left Ear: [Present/Absent by frequency, noise floor issues, probe fit limitations, middle-ear status limitations]

(Do not infer cochlear status if middle-ear dysfunction or high noise is present—explicitly state limitation. If not performed, state reason.)

Electrophysiology Methods

Equipment and Transducers

[Evoked potential system make/model]. [Transducers: insert earphones with tip type/size, bone vibrator model if used]. Equipment calibrated per institutional policy.

Electrode Montage

[Electrode sites], [Impedance values/range], [Artifact rejection approach]. [Notes on myogenic artifact, ECG contamination, or line noise with mitigation steps if applicable].

ABR Parameters

Stimulus Types: [Click / Toneburst / Chirp]

For each stimulus type used:

• Polarity: [Rarefaction / Condensation / Alternating]
• Rate/Window: [Rate in pps], [Analysis window in ms]
• Filters: [High-pass/Low-pass; notch if used]
• Averaging: [Number of sweeps], [Replication approach]
• Masking: [Used/Not used; type and level] (If not masked when cross-hearing is possible, note "unmasked—possible cross-hearing.")
• Bone Conduction: [Oscillator placement, coupling method, masking status] (If performed.)

ASSR Parameters

(If ASSR not performed, state "ASSR not performed: [Reason]" and skip to next section.)

• Modulation Rate: [Protocol, e.g., 80–90 Hz]
• Carrier Frequencies: [Frequencies tested and step size]
• Detection Criterion: [Statistical confidence level]
• Stopping Rules: [Maximum test time, residual noise criteria]
• Masking: [Masking approach]

Units and Correction Factors

[Statement of units: Results reported in dB nHL / dB eHL]. [Correction factors applied: clinic standard / manufacturer / published reference and how they vary by stimulus/transducer]. (If no conversion applied, state "Results reported in dB nHL; conversion to eHL not applied.")

Results

Test Validity

Overall Confidence: [Good / Fair / Limited] — [Brief reasons]. [Per-ear limitations: incomplete bone conduction, high noise at specific frequencies, time constraints, etc.] (Mark inconclusive results explicitly as "Inconclusive.")

Neural Integrity Findings

(Include when neurodiagnostic assessment was performed or ANSD is a concern. If not performed, document: "Neurodiagnostic ABR not performed: [Reason]" and skip table.)

[Click ABR presence/absence and waveform morphology]. [Cochlear microphonic testing results if performed, including polarity reversal findings].

Ear	Stimulus/Level	Wave I (ms)	Wave III (ms)	Wave V (ms)	IPL I–III	IPL III–V	IPL I–V	Comments
Right	[Stimulus/Level]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Notes]
Left	[Stimulus/Level]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Notes]

[Interaural comparisons and observed asymmetries if relevant].

ABR Threshold Estimates

(Use: CR = clear response, RA = response absent, INC = inconclusive, DNT = did not test. For no-response, document "No response at max output of [X] dB nHL." Flag "unmasked—possible cross-hearing" when applicable.)

Right Ear

Frequency (Hz)	Stimulus/Transducer	Threshold (dB nHL)	Estimated HL (dB eHL)	Status	Notes
[500]	[Stimulus; AC/BC]	[Value]	[Value / N/A]	[CR / RA / INC / DNT]	[Masking, replication, artifact]
[1000]	[Stimulus; AC/BC]	[Value]	[Value / N/A]	[CR / RA / INC / DNT]	[Notes]
[2000]	[Stimulus; AC/BC]	[Value]	[Value / N/A]	[CR / RA / INC / DNT]	[Notes]
[4000]	[Stimulus; AC/BC]	[Value]	[Value / N/A]	[CR / RA / INC / DNT]	[Notes]

Left Ear

Frequency (Hz)	Stimulus/Transducer	Threshold (dB nHL)	Estimated HL (dB eHL)	Status	Notes
[500]	[Stimulus; AC/BC]	[Value]	[Value / N/A]	[CR / RA / INC / DNT]	[Masking, replication, artifact]
[1000]	[Stimulus; AC/BC]	[Value]	[Value / N/A]	[CR / RA / INC / DNT]	[Notes]
[2000]	[Stimulus; AC/BC]	[Value]	[Value / N/A]	[CR / RA / INC / DNT]	[Notes]
[4000]	[Stimulus; AC/BC]	[Value]	[Value / N/A]	[CR / RA / INC / DNT]	[Notes]

ASSR Threshold Estimates

(If ASSR not performed, state "ASSR not performed: [Reason]" and skip tables. Use "≤" convention when response-absent below threshold was not confirmed.)

Right Ear

Frequency (Hz)	Threshold (dB nHL)	Estimated HL (dB eHL)	Criterion Met	Status	Notes
[500]	[Value / ≤Value / No response at X]	[Value / N/A]	[Yes / No]	[CR / RA / INC / DNT]	[Masking, residual noise, stopping rule]
[1000]	[Value / ≤Value / No response at X]	[Value / N/A]	[Yes / No]	[CR / RA / INC / DNT]	[Notes]
[2000]	[Value / ≤Value / No response at X]	[Value / N/A]	[Yes / No]	[CR / RA / INC / DNT]	[Notes]
[4000]	[Value / ≤Value / No response at X]	[Value / N/A]	[Yes / No]	[CR / RA / INC / DNT]	[Notes]

Left Ear

Frequency (Hz)	Threshold (dB nHL)	Estimated HL (dB eHL)	Criterion Met	Status	Notes
[500]	[Value / ≤Value / No response at X]	[Value / N/A]	[Yes / No]	[CR / RA / INC / DNT]	[Masking, residual noise, stopping rule]
[1000]	[Value / ≤Value / No response at X]	[Value / N/A]	[Yes / No]	[CR / RA / INC / DNT]	[Notes]
[2000]	[Value / ≤Value / No response at X]	[Value / N/A]	[Yes / No]	[CR / RA / INC / DNT]	[Notes]
[4000]	[Value / ≤Value / No response at X]	[Value / N/A]	[Yes / No]	[CR / RA / INC / DNT]	[Notes]

Cross-Check Summary

• [Synthesis of how immittance, OAE, and electrophysiologic findings align or conflict]
• [Additional synthesis points as needed]
• [Flag unexpected combinations requiring cautious interpretation]

Attachments

[ABR waveforms: ears/stimuli/levels], [ASSR plots if exported], [Tympanograms], [OAE printouts], [Summary charts]

Interpretation

Right Ear: [Degree and configuration estimate], [Type of hearing loss if supported by air-bone comparisons and middle-ear measures; otherwise "type cannot be definitively determined"], [Neural integrity/ANSD impression if assessed].

Left Ear: [Degree and configuration estimate], [Type of hearing loss if supported; otherwise "type cannot be definitively determined"], [Neural integrity/ANSD impression if assessed].

Reliability and Limitations: [Overall reliability statement; list frequencies that are INC, unmasked with potential cross-hearing, affected by noise/artifact, or compromised by patient state].

Comparison to Prior Results: [Consistency or discrepancies with prior testing, dates, and likely reasons] (If no prior results, state "No prior electrophysiology results available for comparison.")

Impression Summary: [Two to three sentences summarizing ear-specific findings, overall type/degree/configuration using appropriately hedged language, and key limitations].

Recommendations

• Medical/Otologic Referral: [ENT referral indicated: Yes/No. If yes, specify reason(s) such as persistent effusion, suspected conductive component, asymmetry, suspected ANSD, abnormal otoscopy, craniofacial concerns, or amplification clearance.]
• Amplification: [If permanent loss suspected/confirmed, recommend hearing aid evaluation; note programming should use frequency-specific, ear-specific estimates updated when behavioral thresholds become available.]
• Early Intervention/EHDI: [For children under 3 with identified or suspected hearing loss, document referral to early intervention and EHDI coordination with timeline.]
• Follow-up Testing: [Testing needed], [Conditions: natural sleep vs sedation], [Timeframe]. [For any DNT or INC frequency, specify what should be repeated.] [Contingency plan if applicable, e.g., "If effusion resolves, repeat air-conduction ABR; if persists beyond 3 months, refer to ENT."]

Signature

Interpreting Audiologist: [Name, credentials] — Signature: ____________________ Date: [Date] Time: [Time]

Testing Audiologist: [Name, credentials] (Include if different from interpreter.)