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The document is a hearing screening form from the Communicative Disorders Clinic at San Francisco State University. It includes sections for patient information, otoscopic impressions, audiometric testing results, and recommendations for further evaluation or consultation.

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What are the normal findings of hearing assessment?

Audiologic function testing (CPT codes 92550-92588) includes testing of both ears, and only one unit of service for any of these CPT codes may be reported for the described testing on both ears. If only one ear is tested, the appropriate CPT code should be reported with modifier 52 [Reduced services].

How to document hearing screening?

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.

How to do a hearing screening with an audiometer?

Applicant screening forms are tools used by a search committee to evaluate applicants based on job-related criteria. These forms should be used to narrow the total pool of applicants to a smaller pool of candidates the search committee wishes to pursue.

What are screening forms?

A screening audiometer is used to identify a potential hearing deficiency. A failed screening would require a referral for a full diagnostic test battery. A diagnostic audiometer would be the first device used in the full diagnostic test battery.

How do you document a hearing 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.

printable hearing screening form

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How to write hearing test results?

Normal hearing (025 dB): At this level, hearing is within normal limits. Mild hearing loss (2640 dB): Mild hearing loss may cause inattention, difficulty suppressing background noise, and increased listening efforts. Patients with this degree of loss may not hear soft speech.