Hearing Screening E-Learning Course

Hearing Screening E-Learning Course

Documentation

Documentation of Risk Assessment and Hearing History

How do I perform a risk assessment/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 hearing screening (standard pure tone audiometry and play audiometry)

This documentation information is for those programs using paper documentation. For programs documenting in an electronic health record (EHR), there should be space to document the ear (right or left), all 4 frequencies presented, and the decibel used to present the frequency. If a recommended or required hearing screen was not performed during a Child and Teen Checkups visit, the reason and a plan for rescreening should be documented.
  • 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 excessive 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 sounds 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

Example of Documentation/ notation of results:
Write the first decibel level that the child was being tested for each of the corresponding frequencies (Hz) (i.e., 20 dB at 1000 Hz, 2000 Hz, and 4000 Hz; and 25 dB at 500 Hz). Then mark with a checkmark if the child heard the sound or with a dashed O if the child did not hear a sound. For example, if the child responded to 25 dB in the right ear at 500 Hz and did not respond to 20 dB at 1000 Hz, your documentation would look like the following:
✔ Heard and responds = PASS
Ø No response = REFER

*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
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 of documentation key for immediate re-screen:

Ø ✔ No response initially but responds on immediate rescreen = PASS/Normal

Ø Ø No response initially or on immediate rescreen = REFER/ Abnormal

If the child does NOT hear all eight sounds during the immediate rescreen, document by checking the “REFER”/Abnormal box and marking “Ø” in the box for the tone that was missed on first attempt and ØØ”on the immediate rescreen. A REFER on the immediate rescreen indicates a referral will be necessary.

For example:

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

C&TC Documentation

Complete documentation of the hearing screening must be provided. Although no specific documentation forms are required for C&TC, age specific C&TC documentation forms are available for your convenience.

For more information on C&TC documentation, or to download the documentation forms, please visit the C&TC Documentation Forms for Clinics and Providers

 

This concludes the Documentation segment of the Results Interpretation and Follow-Up section. You may continue on to the Communicating Results and Follow-Up segment, or return to the Table of Contents. If you do not plan to complete the entire web training, please fill out the evaluation form, C&TC Children's Hearing Screening Web-Based Training Evaluation.


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