Date: 28 Jan 2009
Medical Record Documentation of Patients’ Hearing Loss by Physicians
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Anecdotal evidence suggests that hearing loss, even when sufficient to prevent full access to spoken communication, often is underreported by patients and not documented by physicians. No published studies have investigated this issue quantitatively.
To assess the documentation of hearing loss in comprehensive physician notes in cases where the patients are known to have substantial binaural loss.
Electronic medical record (EMR) notes for 100 consecutive patients with substantial binaural hearing loss were reviewed retrospectively at a large academic medical center. All records reviewed were created within 2 years before the patient’s audiometry. Comprehensive physician notes containing the headings “History” and “Physical Exam” were examined for documentation of hearing loss and scored as: no mention of loss; finding of loss; or hearing reported as normal.
Consecutive adult patients with substantial binaural hearing loss by audiometry who also had a comprehensive medical assessment in their electronic medical record created within 2 years before audiometry.
Thirty-six percent of EMRs had no mention of hearing loss, 28% reported some loss, and 36% percent indicated that hearing was normal.
Substantial hearing loss, sufficient to prevent effective communication in the medical setting, often is underdocumented in medical records.
Iezzoni L, O’Day B, Kileen M, Harker H. Communicating about health care: observations from persons who are Deaf or hard of hearing. Ann Intern Med. 2004;140:356–62.PubMed
Walhagen M, Pettengill E. Hearing impairment: significant but underassessed in primary care settings. J Geront Nur. 2008;34:36–42.CrossRef
American National Standards Institute. S3.5 Standard methods for calculation of the Speech Intelligibility Index. New York; 1997.
Halpin C, Thornton A, Hou Z. The Articulation Index in clinical diagnosis and hearing aid fitting. Curr Sci. 1996;4:325–34.
Picheny M, Durlach N, Braida L. Speaking clearly for the hard of hearing II: acoustic characteristics of clear and conversational speech. J Sp Hrng Res. 1986;29:434–46.
- Medical Record Documentation of Patients’ Hearing Loss by Physicians
Journal of General Internal Medicine
Volume 24, Issue 4 , pp 517-519
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- hearing loss
- electronic medical record
- patient communication
- Industry Sectors
- Author Affiliations
- 1. Department of Audiology Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, 02114, USA
- 2. Institute for Health Policy, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- 3. Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA