Teleaudiology Visit Note

Date: [Date and time] (Include time zone if cross-state)

Patient: [Patient name; DOB; MRN]

Clinician: [Clinician name, credentials, location]

Encounter Type: [new / established]; [device support / counseling / triage / follow-up / other]

Referring Provider: [Name, credentials, organization] (Only include if applicable)

Telehealth Context

(Compliance-critical section. Do not abbreviate or leave items blank. Use "Not obtained—[reason]" when needed.)

• Modality: [audio-video / audio-only] (If audio-only, include brief reason)
• Platform: [Telehealth application or phone service]
• Patient Location: [City, State; full address per policy]
• Clinician Location: [City, State; clinic or home office]
• Identity Verification: [Method used]
• Consent: [verbal / written] (Confirm patient understands telehealth nature, limitations, privacy considerations, and right to request in-person care)
• Participants Present: [patient alone / names and roles of others at patient site]; [others at clinician site if applicable]
• Emergency Plan: [Emergency contact verified; callback number; disconnect plan; safety considerations if applicable]

History

Chief Concern: [Patient-stated reason in their words]

Interval History: [Brief narrative covering onset, duration, progression, laterality of hearing concerns; associated symptoms such as tinnitus, aural fullness, otalgia, dizziness; functional impact on communication; for device visits, describe specific problem] (Clearly distinguish patient-reported information from clinician observations or device data)

Relevant Background: [Pertinent otologic/audiologic history; relevant medical conditions and ototoxic medications; communication access needs; records reviewed] (Include only if pertinent to today's visit)

Device Information

(Include only for device-focused visits; omit entirely if no device involved)

• Device(s): [Type; ear(s); manufacturer/model; dome/mold style]
• Current Settings: [Programs and key parameters]
• Connectivity: [Phone OS; accessories; pairing status] (Include if relevant to complaint)
• Troubleshooting History: [Prior steps attempted and outcomes]

Objective

(Document only clinician-observed or measured findings. Explicitly state items not assessable due to telehealth limitations. Do not imply normal findings when not assessed.)

• Observations: [Speech understanding during call; need for repetitions; visible ear/skin findings if video adequate; audio/video quality constraints]
• Remote Otoscopy: [Equipment; who performed; findings; adequacy] (If not performed: "Not performed—telehealth limitation; recommend in-person otoscopy if clinically indicated")
• Remote Testing: [Test type; environment; calibration status; reliability; results] (If not performed: "Testing deferred due to remote limitations")
• Device Data: [Data logging summary; feedback results; in-situ measures] (Include only if applicable)

Assessment

[Problem-oriented clinical impressions based on available data] (Use "suspected" or "cannot rule out" language when objective confirmation not possible. Explicitly note diagnostic uncertainty due to telehealth limitations. Include risk stratification and referral urgency rationale when applicable.)

Plan

Services Provided:

• [Counseling topics covered]
• [Troubleshooting steps and outcomes]
• [Remote programming changes with rationale and patient response]
• [Home care instructions and resources provided]

Device Adjustments: [What changed; rationale; patient response; rollback plan if adverse effects] (Include only if applicable)

Referrals: [ENT/otology with urgency; in-person audiology with tests requested; other referrals as indicated] (Include only if applicable)

Safety-Net Instructions: [Return precautions and where to seek care] (Always include. Specify symptoms warranting urgent evaluation: sudden or rapidly worsening hearing loss, unilateral weakness or numbness, severe vertigo with inability to walk, ear drainage with fever, severe ear pain. Document patient understanding.)

Follow-Up: [Timeframe; modality; data to obtain before next visit; contingency if symptoms change]