Tinnitus Evaluation & Management Note

Date/Time: [Encounter date and time]

Author/Credentials: [Author name and credentials]

Visit Type: [in-person / telehealth]

Referring Provider/Reason: [Referring clinician and referral reason] (Include only if referral exists.)

Chief Complaint

[Patient-stated tinnitus concern in their own words]

History of Present Illness

[Comprehensive narrative of tinnitus presentation] (Weave into a single coherent paragraph: onset timing and precipitating events; duration and course; laterality; sound quality and whether pulsatile vs nonpulsatile—if pulsatile, whether synchronous with heartbeat; loudness variability and triggers/relievers; associated symptoms including hearing change, vertigo, aural fullness, otalgia, focal neurologic symptoms, or head/neck mass symptoms; noise exposure history; relevant medication/substance use with temporal associations; prior evaluations and treatments with perceived benefit; functional impact on sleep, concentration, mood, work, and quality of life; patient goals and concerns. If a characteristic cannot be determined, document as "unable to characterize." For unilateral or pulsatile presentations, explicitly document presence or absence of red-flag symptoms.)

Tinnitus Impact Assessment

(Include only if standardized questionnaire or screening was completed.)

• Instrument: [TFI / THI / VAS / other] — Score: [Score] — Date: [Date] — Interpretation: [Severity interpretation]
• Additional screening: [Sleep, anxiety, or depression instrument] — [Score] — [Interpretation] (Include only if performed.)

Relevant History

[Concise summary of pertinent history relevant to tinnitus] (Include: prior hearing loss and otologic conditions; cardiovascular disease for pulsatile tinnitus; anxiety/depression; insomnia; TMJ dysfunction; prior otologic surgery. Note significant noise exposure if not covered in HPI. Include current medications only if relevant to tinnitus etiology or treatment—e.g., recent changes, ototoxic agents. Avoid duplicating the full problem list.)

Physical Examination

• General: [Appearance and affect]
• Otoscopy: [External canal, tympanic membrane status, cerumen, effusion]
• Head/Neck: [Palpable masses, thyroid if relevant]
• Neurologic: [Cranial nerve assessment, gait if vestibular concerns]
• Pulsatile evaluation: [Synchronous with pulse: yes / no]; [Auscultation findings: bruits present / absent] (Include only if pulsatile features reported.)
• Somatosensory assessment: [TMJ exam, effect of jaw/neck movement on tinnitus] (Include only if suspected.)

(For telehealth: state examination was limited by modality and specify deferred elements.)

Audiologic Assessment

(Include when audiometry was performed or reviewed. If not performed, include only if testing is being ordered.)

• Pure-tone thresholds: [Degree, configuration, symmetry, air and bone conduction]
• Speech measures: [SRT] — [WRS]
• Tympanometry: [Type and key findings] (Include only if performed.)

Interpretation: [Hearing status summary—normal/sensorineural/conductive/mixed, symmetric vs asymmetric, clinical relevance to tinnitus, communication impact, need for further evaluation] (If reviewing outside audiometry, note date and source.)

Imaging

(Include only when imaging was ordered, reviewed, or explicitly discussed with patient.)

• Indication: [Clinical reason—pulsatile tinnitus, unilateral/asymmetric symptoms, neurologic findings, asymmetric hearing loss]
• Study: [Modality] — [ordered / reviewed] — [Date if reviewed]
• Results: [Key findings]
• Impact on management: [How findings affect plan]

(If imaging considered but not ordered, document clinical reasoning and patient counseling regarding low yield.)

Assessment

1. Tinnitus: [pulsatile / nonpulsatile]; [subjective / objective]; [unilateral left / unilateral right / bilateral / asymmetric]; [recent onset / chronic] with [duration]; [bothersome / not bothersome] based on [questionnaire score / functional impairment]. [Brief synthesis of contributing factors and red-flag features present/absent.]
2. Hearing status: [Normal / sensorineural / conductive / mixed]; [laterality and symmetry]; [communication impact]
3. Comorbid contributors: [Insomnia, anxiety, depression, TMJ dysfunction, other] (Include only if relevant.)
4. Differential considerations: [Conditions to consider with rationale] (Include only if warranted; use "consider" language.)

Plan

Tinnitus counseling and education: [Validation of symptoms; explanation of mechanisms; realistic goals focused on reducing distress rather than elimination; hearing protection guidance; aggravating factors; resources provided; patient understanding and response]

• Sound enrichment: [Strategies recommended—environmental sound, bedside sound machine, apps, wearable generators—with instructions and trial timeframe]
• Hearing aids: [Evaluation recommended; expected benefit for tinnitus via improved auditory input; clarify elimination not guaranteed] (Include if hearing loss present.)
• Behavioral therapy: [CBT or tinnitus-focused therapy; referral details] (Include if significant distress or persistent symptoms.)
• Sleep management: [Sleep hygiene counseling; referral if indicated] (Include if sleep impairment.)
• Medications/supplements: [Discussion of evidence limitations; if treating comorbid condition, specify regimen and clarify tinnitus benefit is secondary] (Include only if discussed or prescribed.)

Additional problems: [Plans for hearing loss management, comorbid conditions] (Include only if applicable.)

Referrals: [Specialty] — [Clinical question] (List only those placed.)

Safety instructions: [Return precautions for sudden hearing loss, acute neurologic symptoms, severe vertigo, worsening symptoms, suicidal ideation] (Include when red flags present or at-risk presentation.)

Follow-up: [Interval and modality]; [Reassessment plan—tinnitus impact, treatment response]; [Escalation criteria]

Orders

(Include only if orders were placed.)

• [Audiometry / Imaging / Referral / Procedure] — [Indication]