Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chronic hearing loss, evaluation of worsening hearing, or hearing aid fitting/adjustment.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of the hearing loss:
Duration and perceived progression of hearing loss
Unilateral or bilateral hearing loss
Difficulty hearing conversations, background noise, or specific sounds (e.g., high-pitched tones)
Tinnitus (ringing or buzzing in the ears)
Dizziness or balance problems (may be associated with inner ear problems)
Impact on daily life (communication difficulties, social isolation)
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying conditions that might contribute to hearing loss (e.g., otosclerosis, Meniere’s disease, noise exposure, head trauma)
Previous surgeries or ear infections
Current medications (some medications can be ototoxic and damage hearing)
Social History:
Inquire about occupational noise exposure (past and present).
Ask about hobbies or activities that might contribute to noise exposure (e.g., hunting, music).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Ear Exam:
Perform an otoscopic examination to evaluate the:
External auditory canal (for wax buildup, foreign objects)
Tympanic membrane (eardrum) for integrity, color, and mobility
Middle ear for signs of infection or effusion
Hearing Assessment (Audiometry):
Review results of recent audiometry testing, if available.
Briefly describe the type and degree of hearing loss (conductive, sensorineural, mixed).
Assessment (A):
Severity of Hearing Loss:
Classify the severity of hearing loss based on audiometry results (mild, moderate, severe, profound).
Functional Impact:
Assess the impact of hearing loss on the patient’s communication, social interactions, and overall well-being.
Etiology (Cause) of Hearing Loss:
Based on history, physical exam, and audiometry, determine the likely cause of chronic hearing loss.
Consider referring to an audiologist for further evaluation if the cause is unclear.
Plan (P):
Treatment Plan:
Develop a treatment plan based on the cause and severity of hearing loss. Options may include:
Medical management: Antibiotics for ear infections, medications for Meniere’s disease.
Hearing aids: Discuss potential benefits and limitations of hearing aids. If indicated, perform a hearing aid fitting and provide instructions on use and care.
Aural rehabilitation: Provide resources for auditory training and communication strategies.
Cochlear implants (for severe to profound sensorineural hearing loss): Referral to an otolaryngologist for evaluation may be necessary.
Follow-up:
Schedule follow-up visits to monitor hearing status, assess hearing aid benefit (if applicable), and address any ongoing concerns.
Define the frequency of follow-up based on the severity of hearing loss and treatment plan.
Patient Education:
Educate the patient about their type of hearing loss, treatment options, and the importance of communication strategies.
Provide information on hearing aid use and care (if applicable).
Discuss potential benefits and risks of treatment options.
Offer resources for support groups or educational materials on hearing loss management.