Hearing Screening: Result Interpretations and Follow-up

Hearing Screening Result Interpretation and Follow-up

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Rescreen and REFER Criteria

The criterion for pure tone audiometry screening referral is the lack of response to any of the screening tones in one or both ears during the 14 to 21-day rescreen as outlined in the pure tone audiometry screening section. Refer to the Pure Tone Audiometry Screening Algorithm on the following page.

Other Considerations

  • If the child is unable to follow directions, refer to the play audiometry section for recommendations on rescreening.
  • If the child is unable to perform play audiometry rescreen:
    • For children three years of age, rescreen within six months.
    • For children four years or older, rescreen within 30 days.
  • If the child has a REFER result (misses one or more tones) after immediate rescreen (refer to pure tone screening procedure), schedule the child for rescreening in 14 to 21 days.
  • If the child has a REFER result (misses one or more tones) on the 14 to 21 day rescreen, refer the child to their primary care provider for middle ear clearance.
  • If the primary care provider provides middle ear clearance or within 8 to 10 weeks, rescreen the child's hearing.
  • If the screener determines if would be of benefit to the referral, threshold screening** may be performed.

*Determining if the child may have middle ear fluid requires advanced training that may be beyond the skill of some screeners.

**Performing threshold screening requires advanced training that may be beyond the skill of some screeners.

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Documentation

Documentation of Risk Assessment and Hearing History

How do I perform a risk assessment and hearing history?

Written documentation should specify the child's name, child's date of birth, and the date of screening. The primary care provider usually performs a hearing risk assessment as part of the health history. Document the information gained in the hearing concerns section of your form, the health history section of the medical record, or on the hearing screening results table. Document any parental concerns of a child's hearing or risk factors for hearing loss. It is recommended that PASS/REFER terminology replace the pass/fail terminology previously used to indicate a child who does or does not need further follow-up.

Make a note regarding any hearing concerns such as pain or drainage. If any of these conditions are present, do not proceed with the audiometric portion of the screening and have a primary care provider examine the child.

Documentation of Pure Tone Screening

  • For each ear, note the results of the pure tone hearing screening and tympanometry (if performed).
  • Document each frequency screened in a manner that indicates the decibel it was screened at and whether the result was a PASS or REFER.
  • Use consistent notations with a key indicating which symbols or words denote PASS and REFER so that results are clear to caregivers/guardians and providers.
  • If excess ambient noise caused the elimination of screening at 500 Hz, document this in the 500 Hz section of the form.
  • Make any pertinent notes under "Comments," such as if the child has a head cold or congestion. If the child does not appear to understand the pure tone audiometry screening procedure after employing play audiometry techniques, check the "Question Validity" or "Unable" box.
  • Check the "PASS" or "Normal" box if the child is able to hear all four tones in each ear.
  • Document if and why pure tone audiometry is deferred.
  • Example: If the child was unable to be screened via standard hand-raising pure tone audiometry or play audiometry, document this and your plan to rescreen as consistent with your screening program or MDH recommendations.

Document the Results as Follows:

Different programs have different forms. Make sure your form either has the following decibel (dB) and Hertz (Hz) information or that you make note of it in your documentation. Below is a sample form.

*Please note screening at 6000 hZ is for children 11 and older.

Right ear Right ear Right ear Right ear Right ear Left ear Left ear Left ear Left ear Left ear
500 Hertz / 25 dB 1000 Hertz / 20 dB 2000 Hertz / 20 dB 4000 Hertz / 20 dB 6000 Hertz / 20 dB 500 Hertz / 25 dB 1000 Hertz / 20 dB 2000 Hertz / 20 dB 4000 Hertz / 20 dB 6000 Hertz / 20 dB

Example of Documentation Using a Notation Key

Note each decibel level and Hertz screened (20db at 1000 Hz, 2000 Hz, and 4000 Hz; and 25db at 500 Hz) as either heard or not heard.
√ Responds = PASS
Ø No response = REFER

In our example, we use a √ if the child heard the tone or a Ø if the child did not hear the tone. For example; if the child responded to the 25dB in the right ear at 500 Hz and did not respond to 20dB at 1000 Hz, your documentation would look like this:

Right ear Right ear Right ear Right ear Right ear Left ear Left ear Left ear Left ear Left ear
500 Hertz / 25 dB
1000 Hertz / 20 dB
Ø
2000 Hertz / 20 dB
4000 Hertz / 20 dB
6000 Hertz / 20 dB
500 Hertz / 25 dB
1000 Hertz / 20 dB
2000 Hertz / 20 dB
4000 Hertz / 20 dB
6000 Hertz / 20 dB

Example Documentation Key for Immediate Rescreen

Ø √ No response initially but responds on immediate rescreen = PASS or Normal.
Ø Ø No response initially or on immediate rescreen = REFER or Abnormal.

Right ear Right ear Right ear Right ear Right ear Left ear Left ear Left ear Left ear Left ear
500 Hertz / 25 dB
√√
1000 Hertz / 20 dB
ØØ
2000 Hertz / 20 dB
√√
4000 Hertz / 20 dB
√√
6000 Hertz / 20 dB
√√
500 Hertz / 25 dB
√√
1000 Hertz / 20 dB
√√
2000 Hertz / 20 dB
√√
4000 Hertz / 20 dB
√√
6000 Hertz / 20 dB
√√

Documentation of Threshold Screening

  • For each ear, document the lowest decibel at which there were two responses per each of the threshold screening frequencies: 500, 1000, 2000, 4000, and 8000 Hz.
  • Using a grid, such as the school hearing worksheet, to document threshold screening results rather than an audiogram reduces the possibility of confusing a threshold screening with a diagnostic procedure performed by an audiologist.
  • Threshold screening documentation is solely to provide more information to a referral; this purpose should be clearly noted.

Child and Teen Checkups Documentation

Provide complete documentation of the hearing screening. Although no specific documentation forms are required for C&TC, age specific C&TC documentation forms are available for your convenience. For more information, refer to C&TC Documentation Forms for Clinics and Providers.

Note: this form is awaiting an update to reflect the EHDI recommended terms of PASS/REFER in place of normal/abnormal. Question validity/retest, may be changed to terminology reflective of current recommendations.

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Communicating Results and Follow-Up

Hearing screening does not take the place of a medical or audiological evaluation or make definitive statements about a child's hearing. Screening results provide basic information on a child's hearing status, which can be used to inform referral and follow-up. Provide parents with verbal communication via an interpreter as needed, in addition to written information in their native language regarding the necessity of the referral. It is important to ensure the parent or guardian has signed, with informed consent, in accordance with the referring or consulting organization's policies and procedures a release, which allows sharing of information between both agencies. It is recommended that PASS/REFER terminology replace pass/fail terminology previously used to indicate a child who does or does not need further follow-up. Fail terminology has negative connotations for children and families. Education staff should be informed of diagnosis and treatment so adjustments, if necessary, can be made in the child's education program. A sample Hearing referral letter is available in Appendix A.

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Monitoring and Follow-Up

The success of a screening program is dependent on the program's capacity to track children who do not pass the initial screening through subsequent follow-up steps, as outlined in the program's written protocol. The protocol should include a plan for how children will be tracked and flagged for rescreening, describe what screening results documentation will be provided to parents and primary care providers, and identify who will explain the screening results to families. In addition, the protocol should have a plan to ensure follow-up has taken place. Programs should periodically review pass rates, monitor and evaluate the program's compliance to their established screening protocol, and review recommended follow-up sequence and timing.

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