This document is a refresher for audiologists and audiometrists on the professional practice standards they must adhere to when writing audiological reports. The Ethics Review Committee (ERC) decided to write this refresher following a number of complaints that may have been avoided if the audiological report provided by the audiologist or audiometrist was of sufficient quality.
Report writing is a basic skill that all audiometrists and audiologists are expected to have mastered by the completion of their internship
Who, where and when
When writing an audiological report, be sure to include basic details on who, where and when:
- Your full name.
- The date any assessments were undertaken and the date the report was prepared.
- Contact details for questions/follow-up.
- The client’s full name.
- Any relevant history for the client.
- What the client’s questions/concerns/requests are.
What and why
It is also important to clearly describe what was done and why it was done:
- Clearly state which assessment tests were undertaken using the technical term for the test.
- Provide a description of what the assessment test(s) are used to assess in terms which the client can understand (e.g. “to determine hearing function”).
Results, implications and a plan
In line with the Scope of Practice for audiologists and audiometrists, assessment reports should include results, implications and a plan:
- An interpretation of the data (including a consideration of the consistency of the findings from different tests);
- A summary of findings;
- Recommendations (including the need for referral); and
- An audiological treatment/management plan.
Precautions, contraindications and warnings
In addition, precautions, contraindications and warnings should also be clearly stated according to Audiology Australia’s Professional Practice Standards Part A: Practice Operations, including stating the following:
- Physical abnormalities or pathologies.
- Precautions taken prior to an intervention (e.g. impression taking).
- Contraindications to particular interventions.
- Client reactions or sensitivities.
The Ethics Review Committee advises against the use of pass/fail columns audiological reports
Pass or Fail columns should not be included in audiological reports. Instead a discussion of the interpretation and/or implications of the findings and treatment options should be documented.
Poor audiological report writing is a breach of the Code of Conduct
It is important to remember that, according to the Code of Conduct Standard 3, members must promote the client’s right to participate in decisions that affect their hearing health. This includes “Promoting the client’s ability to make informed choices in relation to their hearing health by providing sufficient, accurate and up-to-date information in terms which the client can understand”. It also means that clients have a right to have any questions or concerns they have answered, preferably in writing so that they can refer back to your advice later.
A breach of the Code of Conduct by members of Audiology Australia or the Australian College of Audiology would be managed and resolved by the Ethics Review Committee according to the Complaints Management and Resolution Procedure.
My Health Record and audiological reports
My Health Record is an online summary of key health information and all eligible Australians who haven’t opted-out have a record. As an audiologist, you can remind your client that they can upload the audiological report to their My Health Record so that they can refer to it later and other healthcare professionals can view it. Alternatively, you can ask your client to give you permission to upload information to their My Health Record, if this is your client’s wish and you have the appropriate access. For more information on how to register for My Health Record and to learn more about using the system, please see the My Health Record website or contact the Australian Digital Health Agency.