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Audiology Clinical Evaluation — Diagnostic pure-tone audiometry, tympanometry & hearing aid candidacy

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Clinical Documentation

Document Main Title

Subtitle / ISBAR Protocol Header

IIdentification: Patient Demographics, Clinician & Clinic Details

Clinic Profile Auto-Saved

Patient Information

Patient Full Name

Date of Birth (DOB)

Medical Record # (MRN)

Gender / Age

Patient Phone

Attending Clinician / Doctor

Persistent

Clinician Name & Degrees

Clinical Title / Credentials

State License / NPI #

Practice & Referring MD

Persistent

Clinic / Practice Name

Referring Physician

Clinic Address & Phone

SSituation: Reason for Referral & Chief Audiologic Complaints

Primary Referral Reason / Clinical Purpose

Chief Audiological Complaint & Patient Symptoms

BBackground: Otologic History, Otoscopy (AD / AS) & Prior Interventions

Otologic & Medical History

Otoscopy: Right Ear (AD)

Otoscopy: Left Ear (AS)

Prior Amplification / Hearing Aid History

AAssessment & Clinical Diagnostics

audiology

Right Ear (AD) Red • Circle

Degree of Loss

Type of Loss

PTA (dB HL)

SRT (dB)

WRS (%)

Tympanometry

Left Ear (AS) Emerald • Cross

Degree of Loss

Type of Loss

PTA (dB HL)

SRT (dB)

WRS (%)

Tympanometry

Clinical Diagnostic Impression & Summary

RRecommendation: Clinical Plan, Amplification Strategy & Follow-up

Clinical Recommendations & Management Plan

Follow-Up Interval / Next Appointment

Additional Notes / Counseling

HIPAA Confidentiality / Legal Footer Text

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Letter•Portrait

Accent color

Clinical

Optometry

Medical

Rehab

Therapy

Charcoal

Clinical Teal

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Clinic Branding & Clinician Signature

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Signee:Attending Clinician

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PREVIEW • DRAFT

Audiology Clinical Evaluation Report

Date: 2026-08-17

IIdentification (Patient & Referral)

Patient Name-

DOB / Demographics-

MRN / Record #-

Referring Provider-

S Situation (Chief Complaint & Referral Goal)

B Background (Clinical History & Physical Baseline)

Right Ear (AD): -

Left Ear (AS): -

A Assessment & Diagnostic Findings

Ear	Degree of Loss	Type of Loss	PTA	SRT	WRS Score	Tympanometry
Right (AD)	-	-	-	-	-	-
Left (AS)	-	-	-	-	-	-

Diagnostic Impression & Summary:

R Recommendation (Plan of Care & Clinical Management)

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