In the field of audiology, precise and detailed clinical documentation is crucial for effective patient management and care. The following guide provides a step-by-step tutorial on writing and formatting clinical notes for a hearing aid check, using a structured template to ensure comprehensive patient documentation.

Creating a well-organized and thorough hearing aid check document involves several key sections. Below, we outline each component using an example to illustrate best practices.

Subjective Section

This section captures the patient's reported experiences and concerns. For instance, "John Doe was seen for a HA check of Phonak Audeo Marvel hearing aids. He reported experiencing occasional feedback and difficulty hearing in noisy environments." This information is vital as it highlights the patient's primary issues and expectations from the visit.

Objective Section

Here, the audiologist records observable and measurable data. An example entry might be, "Otoscopy: Otoscopy unremarkable bilaterally. Cerumen management was recommended and consent obtained. Wax removal was completed in the right ear using irrigation." This objective data provides a factual basis for the audiologist's assessment and plan.

Assessment Section

This part of the document is where the audiologist evaluates the collected information. For example, "Both hearing aids were cleaned and checked, including changing the domes and wax traps. The sound of the hearing aids was good. Ran HAs in Redux which revealed 5 microliters of moisture being removed." This assessment synthesizes the subjective and objective findings to form a diagnosis or understanding of the patient's condition.

Plan Section

The plan outlines the proposed interventions or follow-up steps. An example is, "Due to patient's concerns of feedback and difficulty in noisy environments, the following adjustments, changes, and recommendations were made: The audiologist adjusted the gain settings to reduce feedback and provided counseling on using the directional microphone feature in noisy settings. It was recommended that John return in 6 months for a hearing aid check which he will call to schedule. Patient was encouraged to call and return sooner if any problems or concerns arise. Pt was provided after visit summary." This section is critical as it directs future care and reassures the patient of their next steps.

The incorporation of AI medical scribes, such as Notis AI Medical Scribe, can significantly enhance the efficiency and accuracy of audiology documentation. Notis utilizes advanced voice-to-text technology to transcribe patient interactions into structured SOAP notes, streamlining the process and allowing audiologists to focus more on patient care.

Time Efficiency and Ease of Use

Notis reduces documentation time by up to 80%, saving audiologists approximately 2 hours per day. Its integration with WhatsApp offers a familiar interface, eliminating the need for additional software and making the transition seamless.

High Accuracy and Comprehensive Documentation

Boasting a 99% accuracy rate in transcribing medical notes, Notis ensures precise documentation. It supports 56 languages, catering to diverse patient populations, and instantly converts consultations into structured SOAP notes, thereby improving the quality and consistency of patient documentation.

By leveraging AI tools like Notis, audiologists can enhance their clinical documentation processes, ensuring they meet professional standards while optimizing their time and resources for better patient outcomes.