“Normal/at-baseline” means functional hearing is at the patient’s baseline, the external ear is unremarkable, and any chronic deficit is unchanged and well-compensated. Each line states the finding, the comparison to baseline, and the skilled reason a nurse was required — a bare “hears okay” does not qualify.
Functional hearing at the patient’s baseline — responds appropriately to conversational voice, with hearing aids as used — without new change.
No new or sudden hearing loss, muffling, or asymmetry.
External ear and canal without deformity, swelling, drainage, or obstructing cerumen, where inspected.
No otalgia, drainage, or fever; tinnitus absent or at the chronic baseline.
No vertigo, or chronic positional vertigo at baseline without new neurologic signs.
Hearing aids fitted, functioning, and used and maintained correctly.
Balance at the patient’s baseline and the communication strategy effective, with the plan appropriate to continue.
