As an audiologist, the ability to efficiently document clinical encounters is crucial for patient care and continuity. The Annual Hearing Test/Hearing Aid Check (HT HAC) template provides a structured approach to documenting audiological assessments. Here's a detailed breakdown of how to correctly write and format this type of documentation.

Patient Introduction and Medical History

Begin by introducing the patient and summarizing any updates in their medical history. This section is crucial for establishing the context of the visit.

Example: "I had the pleasure of seeing John Smith, age 67 years for an annual HT/HAC. During today's appointment, the patient reported the following audiological and medical history updates."

• Changes in Medical History: Note any recent diagnoses or changes. For instance, "Recently diagnosed with hypertension."

• Hearing Aid Use: Document the patient's experience with their hearing aids, such as "Patient reports using hearing aids comfortably for 8 hours a day."

Hearing Test Results

Conduct a thorough hearing test and document the findings, ensuring clarity and precision.

Example: "Otoscopy (Bilateral): Clear ear canals. Hearing recheck indicated the following: a moderate loss for the right ear and a mild loss for the left ear. Word recognition scores indicated: 88% for the right and 92% for the left."

Hearing Aid Check

Detail the checks performed on the hearing aids, highlighting the maintenance and performance results.

Example: "Redux completed removing all moisture. Cleaned both HAs, including wax trap and dome replacement. Subsequent listening checks were good. Data shows 8 hr/day use. Electroacoustic analysis and directionality testing completed. Devices meet manufacturer's specifications. REM completed on both devices with good results at all input levels (55/65/75 dB). No other programming changes made during this time. All patient's questions answered satisfactorily."

Patient Education and Recommendations

Conclude with patient education and follow-up recommendations to ensure continued care and patient satisfaction.

Example: "Reviewed technology usage instructions, demonstrated proper cleaning techniques, and provided instructions for auditory training to improve hearing. Recommendations: Patient to return in 6 months for a follow-up hearing aid check and annual hearing test."

Incorporating AI medical scribes like Notis AI Medical Scribe into your audiology practice can transform the documentation process. Notis utilizes cutting-edge voice-to-text technology to generate accurate and comprehensive SOAP notes, allowing audiologists to focus more on patient care rather than paperwork.

Benefits of Using Notis AI Medical Scribe

Notis stands out for its ability to significantly reduce documentation time, offering up to 80% time savings. Users benefit from a familiar interface via WhatsApp, ensuring ease of use without the need for additional software.

With a high accuracy rate of 99%, Notis supports multilingual transcription, catering to diverse patient populations, and ensures comprehensive documentation through structured SOAP notes. Its smart search and retrieval features allow audiologists to access patient information swiftly using natural language queries.

Conclusion

Integrating Notis AI Medical Scribe into your audiological practice enhances the efficiency and accuracy of patient charting, ultimately allowing you to dedicate more time to what truly matters—patient care. By streamlining the documentation process, Notis empowers audiologists to provide high-quality care while reducing administrative burdens.