Effective clinical documentation is crucial in audiology to ensure accurate patient records and seamless communication among healthcare professionals. The GA ABR (General Anesthesia Auditory Brainstem Response) report is a specialized document that audiologists use to assess hearing, especially in patients who cannot respond to conventional hearing tests. This guide provides a comprehensive approach to writing and formatting a GA ABR report, ensuring clarity and completeness.

To draft a clear and professional GA ABR report, it is important to follow a structured template. Here is a detailed walkthrough using an example:

Patient Information

Begin with the patient's details, including the full name and the purpose of the visit. For instance:

Patient Name: Emily Johnson was seen today for Auditory Brainstem Response testing under general anesthetic.

History

Provide a concise history that outlines why the patient was referred for the GA ABR test. Include relevant medical history that may impact the hearing assessment. For example:

Emily was referred by Dr. Thomas Kelly, a pediatric ENT specialist, for further evaluation due to concerns about her hearing development. Emily has a history of recurrent ear infections and had tympanostomy tubes placed six months ago.

Summary of Assessment

This section summarizes the findings from the hearing assessment. Use specific terms and results to convey the outcomes clearly:

The hearing assessment was carried out immediately after ENT review. ENT reported that the ears appeared clear, and the grommets were still in place. Results suggest that the Otoscopy showed clear ear canals, Tympanometry indicated normal middle ear function, Distortion Product Otoacoustic Emissions were present, and Auditory Brainstem Response testing revealed mild sensorineural hearing loss in the right ear and normal hearing in the left ear.

Plan

Outline the proposed plan of action based on the assessment results. This should include treatment recommendations, follow-up appointments, and any additional therapy needed:

1. Recommend fitting of a hearing aid for the right ear to support hearing development.
2. Schedule a follow-up appointment in three months to monitor hearing status and grommet function.
3. Encourage regular speech and language therapy sessions to support communication skills.

Include a note about the variability of hearing over time to manage expectations:

Please remember that hearing can change over time for several reasons. Today's results do not indicate what hearing might be like in the future. If there are any concerns regarding hearing or speech and language development at any time, another hearing test should be arranged.

Incorporating AI medical scribes like Notis AI Medical Scribe can revolutionize the way audiologists handle patient documentation. Notis automates the transcription of patient interactions into structured SOAP (Subjective, Objective, Assessment, Plan) notes, significantly reducing the time spent on administrative tasks.

With Notis, audiologists can benefit from:

Time Efficiency

Notis cuts down documentation time by up to 80%, allowing audiologists to dedicate more time to patient care rather than paperwork. On average, users save 2 hours per day, which enhances productivity and reduces burnout.

Ease of Use and Accuracy

Operating through familiar platforms like WhatsApp, Notis ensures a seamless transition without the need for additional software. The voice-to-text technology boasts an impressive 99% accuracy, ensuring that medical notes are precise and reliable.

Comprehensive Documentation and Smart Retrieval

Notis offers structured SOAP notes, enabling audiologists to easily manage and retrieve patient information. With its natural language query capability, accessing patient records becomes straightforward and efficient.

By integrating AI medical scribes into audiology practices, professionals can improve the efficiency and accuracy of patient charting, ultimately leading to better patient outcomes and streamlined clinic operations. Embracing technology like Notis AI Medical Scribe empowers audiologists to focus on what truly matters—providing exceptional patient care.