Tag: report

How you obtain and record audiometric data—or how you structure your “Audiogram Form”—is important for relating necessary information to the patient, physicians, and other health care professionals, including (and especially) your own practice staff members. In a recent article1 in HR, I promoted the idea that we should all be constantly asking ourselves, “Why am I doing this test for this patient, and why am I doing it in this order?” If our answer is “Because that’s the way I was taught to do it” or “That’s the way I’ve always done it,” then it is time to revisit our rationales and try to objectively determine if this approach is the best one. The article then went on to address the Patient History Form—an important tool used in dispensing offices for screening patients for “red flags” that would warrant immediate referral to a physician. Additionally, the patient history and its related form should provide you with a reasonable “first look” or estimation of the patient’s degree and slope/configuration of hearing loss, nature of the loss (conductive, sensorineural, or central), and its impact on the individual. Similar to Part 1 on Patient History Forms, this article concerns itself with the “Audiogram Form” (which generally also includes other audiometric tests). One salient point is that your test battery should have a logical and appropriate order so as to contribute to the gestalt of your and your staff’s hearing assessment, while providing for an optimal patient experience, with a logical “flow” that minimizes movement and/or switching settings on their part. It is important to keep in mind that patients age 65 or older have on average 30-45 minutes of high quality attention time; you need to the pertinent information in this time. Jay B. McSpaden, PhD, CCC-A, BC-HIS, is an audiologist who retired from private practice and currently works part-time as a hearing instrument specialist in Jefferson, Ore. In this discussion, one should be aware that insurance companies have forms that vary and evolve; likewise, any practitioner has his/her own work flow and perferred tests. Therefore, the information presented here is not intended to be didactic; it is “food for thought” for comparing your own current test battery and reporting system. Brief Overview of the Audiogram Form. The Audiogram Form (Figure 1) used in our practice is a single two-sided sheet on which we have the ability to make statements about the patient’s general auditory system function. The upper third of the form contains the identifying information, including our practice logo, location, and contact information. At the top left is the patient’s name, age, date, address, the referral source, as well as the patient’s physician and phone number. Finally, the audiometer make and model are listed. The middle-third of the front side is used to contain a right and left audiogram. We insert all the appropriate marks and symbols into and on this audiogram form. It is important to have a separate space for information generated from the data on both right and left ear. Below this is a summary of the results divided into two sides. On the right-hand side below the “Figure Legend” is the set of symbols used in the form. At the center in the bottom third are five lines in which a brief preliminary report can be written. On the back side of the Audiogram Form is the tympanometric data for the right and left ears. There are also spaces for the ipsilateral reflex data, contralateral reflex measurement, reflex decay information, and a Sensitivity Prediction by Acoustic Reflex (SPAR) test (performed if necessary). Additionally, there is a space for the patient’s name, the date, and the examiner’s name (important should this be the only testing procedure performed and/or if only the back of the form needs to be copied). The bottom half of this back side of the Audiogram Form is used for “half lists” of the CID W-22 word lists. They are provided so that either “recorded” or “live voice” Word Discrimination Test scores can be generated using masked monosyllabic words. These are not the only lists available, but they are the ones currently used in our clinic. The contents of the back of our form are copied “head to toe” because they are “pinned” into the chart at the top center. We can just turn up the page and read the results of the audiometric test battery used as appropriate for individual patients (Table 1). FIGURE 1A and 1B. The front (left) and back (right) of our office’s Audiogram Form. We actually copy the back of the form (second page) in a “head-to-toe” fashion so that tympanometric data on the back of the form can be quickly added to the front. Full-size versions of this form are available as downloadable pdfs – just click on the images above. Using the Form: Starting at the Back with Impedance Testing. After taking the Patient History1 and performing otoscopy, we start at the back of the form (Figure 1b) with the tympanometric boxes. These are marked off in cc’s of equivalent volume and have a scale along the abscissa of mm of water pressure, with a range of +300 mm of water pressure to -300 mm water pressure and from 0.2 to 2.6 cc of equivalent volume along the ordinate or “Y” axis. Also along the ordinate, about one-third of the way from the top, is a “time marked” section that is 14 seconds long. This can be used with a printer for acoustic reflex decay measurements. In our clinic, these data are generated manually and then transcribed onto the right and left Audiogram Form at the appropriate units of volume and pressure. The points measured are then connected so as to describe the right and left tympanograms at the correct units of pressure and volume. Acoustic reflex threshold measurements are made from contralateral presentations of the signal through the earphone. These are measured through the probe tip in the contralateral ear. The threshold measurements are reported on the form under that ear into which the signal is inserted. The ipsilateral measurements are always written on the side into which the signal was delivered. If reflex decay procedures are performed, they start at 1000 Hz with contralateral presentation. This is at the threshold for the reflex plus 10 dB for 10 seconds. If the results of the reflex change fall 50% or less in the steady state during the 10 seconds, the results are “positive” for “reflex decay.” If this is the case, a test is run at 500 Hz looking for the same response. TABLE 1. Summary of the audiometric test battery presented in this article and its coverage of different sites of lesion. On the other hand, if there is less than 50% decrease or no decrease when the stimulus is presented at threshold plus 10 dB for 10 seconds, the results are said to be “negative” for involvement of the VIIIth cranial nerve. In this case, the 500 Hz test is not performed. The Audiogram Form is then turned back over (to the front of the form), and this data is summarized on the actual audiogram. The data for the right ear are recorded on the right side and those for the left are recorded on the left, placing an R or an L with a circle around them at the appropriate frequency and intensity. This permits us to see the recruitment at frequency as the “reflex threshold” approaches the “hearing threshold” within 65 dB. For example, if the reflex was measured to be 85 dB at 1000 Hz, an “R” with a circle around it would be entered at 85 dB on the 1000 Hz line of the appropriate ear. We repeat this process at 500 Hz, 2000 Hz, and 4000 Hz for each ear specifying the measured thresholds at the correct frequencies. In the event that there is no response at a frequency, we leave that space blank. These measurements always refer to contralateral reflexes. When there are none but an ipsilateral reflex is present, this is shown as an “R” with a circle and the notation “Ipsi.” On the “Summary of Results,” there is a space for “Tympanogram Type.” In this space goes either A or a subset of A, B, or C. (For a basic review of tympanometry, see McSpaden.2) Below that is a block to indicate the results of “Reflex Decay” testing. We view that as positive, negative, or blank. Positive reflex decay is a possible indicator of involvement of the VIIIth cranial nerve. Tests in the Sound Booth. Speech MCL. The patient is then placed in a sound-treated room, and a number of tests are preformed. The first procedure is for the elicitation of the Most Comfortable Level (MCL) for speech, the results of which are noted in the summary. In addition, a bar about two-thirds as wide as the two adjacent intensity lines is placed between 500 and 2000 Hz at the measured level with”MCL” written in it. The measurement is done ipsilaterally in each ear and then bilaterally. This number is written as a fraction of Right/Left (as X/Y) in the MCL box marked “bin.” Word recognition/speech reception testing with masking. The next procedure is the Speech Recognition Test (SRT) or Word Reception Test using either an ascending or descending presentation method. One can do this using the standard CID W-1 word lists in a “live voice” or via recording. The elicited SRT (or WRT) is entered into the summary. This is followed by the Performance-Intensity Phonetically-Balanced (PI-PB) test, which is a version of the speech (or word) discrimination test. This yields the maximum potential score for “phonetically balanced” words (the so-called PBmax). It is also the score elicited at a maximum level of 90 dBHL, which allows us to look for the possibility of PI-PB rollover—an indicant of possible VIIIth nerve involvement. Again, these tests can be done using recorded presentation or by live voice. Before we leave this brief discussion of procedures, it is necessary to say that, in our clinic, all speech discrimination testing is done using masking in the non-test ear. The masking signal is a white noise, and it is usually presented in the following manner: If the otoimmittance indicates...

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