Use when functional hearing is at baseline and the external ear is unremarkable. Fill the bracketed blanks with the visit’s actual findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled functional ear and hearing assessment completed. Functional hearing at baseline — responds to conversational voice bilaterally [with hearing aids]; [no] new or sudden loss, muffling, or asymmetry. External ear and canal without deformity, swelling, drainage, or obstructing cerumen; [no] otalgia or fever; tinnitus [absent/at baseline]. [No vertigo / chronic positional vertigo at baseline without neurologic signs]; balance at baseline. Hearing aids fitted and functioning, used and maintained correctly. The functional assessment and external-ear exam against baseline confirm stable hearing and vestibular status and continued appropriateness of the plan; hearing-aid care and the warning signs of sudden loss or central vertigo were reinforced with the patient/caregiver, who [teach-back result] (cross-reference Communication, Safety, Neurological).
Short form
Skilled ear/hearing assessment: functional hearing at baseline bilaterally [with aids]; no sudden loss; external ear clear; no otalgia/drainage; no vertigo with neuro signs; aids functioning. Plan continued. Aid care and warning signs reinforced, teach-back correct.
