Audiology Consultation Note

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Shoulder stiffness and discomfort with overhead reaching, developing gradually over six weeks.

Assessment:
Movement restriction affecting daily activity.

Plan:
Agreed a graded home exercise programme and activity modification. Review progress in three weeks.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Audiologist Consult Note

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

[Impact on daily life, communication difficulties, occupational or social effects]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions, especially otologic, neurologic, or systemic diseases]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug, food, or environmental allergies]

Family History:
(hyphenated list)
- [Hearing loss, otologic disorders, genetic conditions]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures to noise or ototoxic agents]
- [Living situation: who lives with patient, home environment]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Ear examination: external ear, canal, tympanic membrane findings]
- [Cranial nerve assessment if relevant]
- [Other relevant systems]

Audiologic Assessment:
(hyphenated list)
- [Pure tone audiometry: degree, type, and configuration of hearing loss]
- [Speech audiometry: speech recognition thresholds, word recognition scores]
- [Immittance testing: tympanometry, acoustic reflexes]
- [Otoacoustic emissions]
- [Other specialized tests: ABR, ECochG, vestibular testing]

Investigations:
(hyphenated list)
- [Relevant laboratory or imaging results]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary audiologic diagnosis]

#) [Assessment as a numbered item if multiple issues]
(hyphenated list with each corresponding plan item on a new line)
- [Further audiologic or medical investigations planned or ordered]
- [Treatment plan: hearing aids, assistive devices, medical or surgical referral]
- [Counselling discussion: communication strategies, prognosis, education]
- [Referrals sent: ENT, neurology, speech-language pathology, etc.]
- [Follow up plan]
- [Return precautions]