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Reporting audiometric results

2008; Lippincott Williams & Wilkins; Volume: 61; Issue: 9 Linguagem: Inglês

10.1097/01.hj.0000339500.44432.90

2333-6218

Brad A. Stach,

Delphi Technique in Research

Our guest author this month is Brad-A. Stach, PhD, director of the Division of Audiology, Department of Otolaryngology-Head and Neck Surgery, of the Henry Ford Medical Group and Henry Ford Hospital in Detroit. A few months ago I sat down with Brad and asked him to give me some good ideas for Page Ten topics, maybe even something he would be willing to write about. Knowing that he is a “medical center guy,” I was expecting him to suggest some hot topics on pathologies, emerging audiologic diagnostic procedures, or maybe special treatment strategies. Instead, he suggested the topic of report writing! Perhaps noticing my frown, he quickly explained that at a recent staff meeting he had asked his four audiology externs what they thought was particularly good and unique about their training experience at Henry Ford. They concluded it was the reporting strategies. And so, our topic for this month was born. In addition to being an annual contributor to HJ's Journal Club Review, Dr. Stach is the author of a number of scientific articles, books, and book chapters. He serves on several editorial boards, is editor-in-chief for audiology for Plural Publishing, and is a faculty member at Wayne State University. He was a founding board member of the American Academy of Audiology and served as its president and as chair of the AAA Foundation board of trustees. The second edition of his popular book Clinical Audiology: An Introduction will be out in a few months–just in time for the holidays. The fact that in his youth, Dr. Stach wrote an audiology dictionary, which has even been translated into Chinese (at least he thinks it's Chinese), tells you quite a bit about his lifestyle. I've learned, however, that nowadays when he's not thinking about report writing or playing golf, you can find him following around his two young daughters or training for the Chicago Marathon, a little jog through his hometown that he does on occasion—always remembering, of course, to visit mom and stop for a slice of his favorite Lou Malnati's pizza! Brad's article reminds us all to think a little about how we write reports, and how others might view and interpret our reports. Is more always better? And, if you're having trouble finding just the right word, well…there is this dictionary. GUS MUELLER Page Ten Editor Used with permission, Porky Pig 1 Your topic is report writing? Seriously? Yes, seriously. Report writing is something we do in our clinical practices everyday. We have to document our findings accurately and communicate results effectively to a variety of other professionals. It is important that we do it well. 2 Captain Obvious to the rescue! I know, I know. But I am amazed at what I see out there when I look at audiology reports. And I am reminded annually, as we bring on new externs from universities around the country, how devoid our students seem to be of strategic direction when it comes to communicating results of their work. 3 Strategic direction for writing a report? It's not that complicated, is-it? Well, I would contend that you at least ought to have a plan. Recently, one of our ENT colleagues and referral sources here at Henry Ford Hospital called me, somewhat exasperated, saying, “I just do not understand the reports from balance function testing.” I resisted the urge to say, “Join the club,” and instead started an internal review of the nature of reporting throughout our clinic. To be sure, the balance function testing reports had evolved to a certain extent along with the general strategies of our other reporting, but equally surely, they remained unclear. So we began the assessment process by delineating the underlying strategies that guide our other reporting, namely: (1) separating documentation from reporting, (2) simplifying and standardizing the language used for effective communication, (3) getting the order right, and (4) emphasizing important outcomes and recommendations while remaining silent on those that are not. 4 Can I assume you are going to explain these? Only if you ask. 5 Okay, why are you trying to differentiate between documentation and communication? It is important to distinguish between documentation of test results and reporting of test results. Documentation is a fundamental necessity of patient care. It is important for continuity of patient care, for billing purposes, and for legal reasons. Documentation is simply the preservation of examination and test results in a patient file, and it must be maintained in all cases following the provision of services. In most audiology clinics, documentation of history and testing outcomes is done on the audiogram form. Here, in important detail, the results of pure-tone air- and bone-conduction audiometry, speech audiometry, and immittance measures are usually included. The over-achiever might even include how much masking was used. In specialized testing, such as the auditory brainstem response measure, documentation usually includes waveforms, recording parameters, and amplitude and latency measures. Again, documenting all this is crucial, but truly no one but us understands what all of it means. So it is incumbent on the audiologist to summarize these data for reporting purposes. Reporting results, then, is simply summarizing the documentation. That is, in some format or another, all of these documented data are interpreted and converted into report form as a means of effectively communicating the findings. If there is a common flaw that I see in the reporting of results it is in the failure to compartmentalize these two issues. 6 What do you mean by that? Let me give you an example. When you carry out immittance testing, you obtain a large amount of detailed information about the tympanogram peak, static immittance, volume measurement, tympanogram width, reflex thresholds, etc. This is, of course, important information to document as part of the patient record. However, most of those who might view the medical record—the primary-care physician, the pediatrician, some other referral source, or the patient—won't understand any of it. So, we write a report that summarizes and interprets these outcomes. What we might actually write in the report is something like “normal middle ear function,” an important and clear summary statement about the test results. But what I often see is a regurgitation of the measurement outcomes rather than a clear summary of the findings. The measurement outcomes serve as the documentation; the summary serves as the report. Let me give you another example. Diagnostic ABR reports are a wonderful study in the often confusing blending of documentation and reporting. If you haven't read one of your own ABR reports lately, take a look at it. Chances are it summarizes for the reader your electrode montage, click polarity, click rate, and maybe even the size of the electrical pulse used to generate that click. All of that is important documentation, but imagine for a-moment the poor, innocent reader who must filter all of that out to find some semblance of a report of the outcome. One of the simplest ways we can improve audiology reports is to delineate and separate those aspects of the report that serve as documentation from those intended to summarize the outcome. Your reader might actually be someone who cares about the velocity of right-beating nystagmus, but the odds are against it. Although thoroughness is an important attribute of documentation, succinctness is an important attribute of reporting. In many clinics, reporting is done in a summary section right on the audiogram form. In other clinics, a separate document is generated, usually intended for the referral source or a third party. Regardless of the form of reporting, there are some fundamental rules for generating effective results. 7 I'm ready. Tell me about some of those fundamental rules. Well, as I mentioned earlier, it is important to work on simplifying and standardizing the language, which is a fundamental part of an effective reporting strategy. There are a finite number of outcomes on our test measures, and I think that 95% of our findings and recommendations can be described in a few handfuls of ways that can be incorporated into templates and used to convey outcomes in a standard way. One way I approach the challenge of describing testing outcomes is to give the referral source and the patient the right words to use to describe the hearing loss. Again, that may sound obvious, but it can help in a number of ways. If your report says the patient has a mild sensorineural hearing loss, there is a good chance that the primary-care physician or the ENT resident reading your report will use those same words. If you have conveyed those same words to the patient, there will be no confusion. This may help avoid the use of some of the more colloquial expressions like nerve deafness or other terms that add confusion. Giving the correct terminology also enables the patient to access accurate information online more readily than if colloquialisms are used. There are two simple rules: (1) Use consistent terminology, and (2) make it clear and concise. 8 Can you be a little more specific? What terminology should be used? That's a good question. If you showed 10 audiologists an audiogram that sloped from normal hearing in the low frequencies to a severe loss in the highs, you would likely get 10 different descriptions of that loss. That's not very helpful to anyone. There have been attempts to develop standard descriptions. I have suggested a fairly simple and concise way of describing audiograms.1 You should also take a close look at the work of Margolis and Saly.2,3 These authors have developed and validated a straightforward system for characterizing hearing loss in terms of configuration, severity, and site of lesion. Regardless of the terminology used, it is probably in your clinic's best interest to adopt a common strategy across providers as a way of ensuring consistent communication to referral sources and patients. A tenet of our reporting strategy is to keep the description of history, hearing loss, immittance measures, and disposition as simple, concise, and clear as possible. If a hearing loss is mild throughout the frequency range but is moderate at one frequency, I encourage you to go wild and refer to the whole thing as a mild hearing loss. Your thresholds are documented elsewhere, so you'll be only slightly wrong, and your patient, her family, their extended family, the ENT resident, the primary-care physician, and everyone but your supervisor will be thrilled to refer to it as a mild sensorineural hearing loss rather than “a mild sensorineural hearing loss below 1500 Hz and above 3000 Hz and a moderate sensorineural hearing loss at 2000 Hz.” The former is simply a more effective way of communicating and giving the patient and the referral source the best words to use to describe the problem. 9 Earlier you mentioned getting the order of a report correct. What do you mean by that? At the Henry Ford Hospital, much as in any modern healthcare system, medical records are maintained electronically. Reports of audiometric testing, infant hearing screening follow-ups, ABR results, balance-function testing, and hearing aid fittings are all available to all providers throughout the system. In our early days of reporting, we were likely to organize a report in the same manner that we learned in graduate school—from an elaborate description of the history, through the assessment methods, and on to results and recommendations. But in a busy healthcare setting, that sequence is nearly the reverse of what is important in terms of the effectiveness of reporting. Imagine that you are a busy pediatrician, seeing scores of children in a morning. One of them failed a hearing screening at birth and was re-evaluated at 6 weeks of age. You have limited time to absorb the details of the report of that follow-up. What's the first thing you want to know? The child's birth history? The click rate of the ABR? How about the polarity of the click? The latencies of wave V? Probably not. With this idea in mind, we have essentially inverted our reports from the standard format to provide our clinical conclusions first, at the top of the report, to facilitate efficient communication of the findings. After a very brief statement of why testing was done comes the interpretation of findings. The documentation of actual results and the nuances of testing are included at the end of the report, just in case anyone might care. So, for an electronic patient record system, where the report and documentation may be combined, it's not a bad idea to sequence the report so that the conclusions come first and the documentation last. This way, anyone reading the report will be able to get to the conclusion without having to wade through the details. 10 You also talked about emphasizing important outcomes. That's fairly obvious, isn't it? Again, I think it is a good idea to view things through the reader's eyeglasses. The more unimportant information the reader is forced to wade through, the less likely he or she is to spot something of importance in the report. 11 Through my eyeglasses that makes no sense. Can you explain? Let me give you two examples. I like to avoid mentioning normal or predictable outcomes when they add absolutely nothing to a report. Word-recognition scores are a perfect case in point. The vast majority of the time they add nothing to the overall equation. Scores are mostly normal or predictable from the audiogram. Saying they are normal or predictable is a waste of communication opportunity. The readers will begin to gloss over such clutter because it adds nothing to the outcome. Now, let's suppose that scores are abnormal. You have already trained the readers to ignore your message, and now you want them to pay attention. Perhaps you could write it in red, but a more effective approach is to mention it only when it is meaningful. It is much more likely to be noticed. Here's another example. We recently saw a patient whose acoustic reflex pattern was consistent with retrocochlear disorder on the right ear, characterized by absent right crossed and right uncrossed reflexes. The way the immittance results were written, the referring physician would have had to understand acoustic reflex patterns fairly thoroughly to see the issue. The audiologist who saw the patient and wrote the report was somewhat miffed that the MD didn't react to these findings. But I contend that it was our fault for not communicating more effectively. Let's face it, reflexes are hard for people to understand, and we may not be great at communicating what they mean. Instead of describing the nuances of the immittance test battery outcome, the audiologist should have stated, “Normal middle ear function bilaterally; however, all reflexes with sound to the right ear are absent, consistent with retrocochlear disorder,” or something like that. The point, then, is to say less when it doesn't matter, so that your communication is effective when it does matter. 12 You said something earlier about avoiding elaborate case histories. Aren't we supposed to gather case histories? Yes, once again, it is important to document thoroughly the patient's case history if that is part of your assessment. But reporting it is quite a different story. There is seldom much need to rehash the case history in a report. Sometimes a description of relevant historical information can be useful in the initial portion of a report, and it is clearly an important part of the documentation in a patient record. But, in most cases, it should be very brief in a-report and serve more as an orientation as to why the consultation took place. 13 But we were taught in graduate school to be thorough on this point. Our speech-language pathology professors couldn't all be wrong, could they? It gets back to why you are writing the report and to whom. If you are being consulted by a physician for a hearing evaluation, there is a very good chance that the referral source has also done and documented a fairly rigorous history and physical. What is there to add? Or maybe the patient is self-referred and would be the only one receiving the report. Clearly, restating the case history will be of little value. The history is not unimportant, but reporting it often is. 14 My guess is you also have some advice about making recommendations and referrals. Am I right? You are. I've already covered the basics: Be clear, be concise, and be consistent, so none of that is new. If you are recommending bilateral amplification, say so. If hearing aid amplification is not indicated, it can be equally important to say so. It is also quite okay to say that no further audiologic follow-up is indicated. If anything bothers me about recommendations, it is the perfunctory or hollow ones, without which the report would be just fine. I hear the occasional student ask incredulously, “You're not going to make any recommendations?” No, not if there are none to make. “But I have to say something at the end of my report.” Not really, not if there isn't anything to say. Recommendations such as “re-test as needed” or “re-test per ENT” do not say anything at all. Sometimes these things just become bad habits. I also find some of the recommendations I see on pediatric testing to be somewhat chilling. Behavioral results could not be obtained due to the child's recalcitrance, and the recommendation becomes one of “re-evaluation in 3 months,” as if the answer to the question were not important enough to get tomorrow. My final point about recommendations is more for the sake of our referral sources. Diagnosing the cause of a hearing disorder is the purview of the physician. During audiometric testing, of course, we may see some findings that can assist in that diagnosis. We also might have additional testing that can elucidate the issue. Our recommendation shouldn't be for this additional testing. That limits the referral source's options from a medical-legal perspective. For example, I don't recommend saying, “We recommend ABR testing to rule out retrocochlear disorder.” That obligates the referral source. Rather, our recommendation should describe the notion that “we noticed some findings that you should be aware of. If you need anything more from us in terms of additional diagnostic information, you should consider a referral for ABR” or ENG, or whatever it may be. 15 So, do you or don't you recommend making a statement about etiology? Again, the diagnosis of cause is the purview of the physician. A description of the presence, the site, and the functional consequences of the disorder may be helpful, but I think reporting is most effective when it emphasizes exceptions. The vast majority of sensorineural hearing loss is of cochlear origin; saying so is most often redundant. However, in cases where the reflex patterns and pure-tone and speech audiometric outcomes are consistent with retrocochlear disorder, it is important to find an effective way to communicate those findings. 16 Anything else you want to ramble on about? There are a couple of documentation issues that are important to consider pertaining to the audiogram itself. Some of our colleagues in other professions, particularly otolaryngology, are quite adept at looking at our audiometric outcomes for their information on the patient's hearing. The audiogram in this case becomes a form of a report and must, therefore, be clear, concise, and consistent. But there are some practices that have become conventional that I think interfere with conveying audiometric information clearly and accurately. Plotting no-response symbols on an audiogram is one example. Countless cases of severe and profound sensitivity loss with no-response bone-conduction symbols have been misinterpreted as mixed hearing losses because of this odd and ancient custom of plotting no-response symbols. It is far more effective to note these under or beside the audiogram than to risk confusing the issue. I think of plotting vibrotactile responses similarly. It just begs for misinterpretation. I'm also not fond of plotting responses that do not represent true threshold. Most audiogram forms have a space on them somewhere for a comment about reliability of pure-tone audiometry. This is appropriate for pediatric testing, but I think it's inappropriate for adult testing. 17 But if the responses aren't reliable, shouldn't you say so? If the responses are not reliable, you shouldn't even plot them on an audiogram that will go into the medical record. Thresholds should be thresholds unless clearly noted on the audiogram. Someone's judgment about “fair” reliability is awfully difficult to interpret after the fact. We teach students to note on the audiogram that valid thresholds could not be established if the reliability of responding is in question. 18 Anything else you don't like about reports? As professionals, we are consulted to make decisions about test results. I think it is important to make those decisions. I don't like words like “borderline.” I've seen this used in cases of minimal hearing loss and in reports of auditory processing disorder (APD) testing. A report that says that the outcome was “borderline normal” does not tell me anything. It's our job to interpret the shades of gray. 19 Any last thoughts, or should those have gone at the beginning? Funny. I recommend that all audiologists do a periodic review of their own documenting and report writing to ensure against the insidious influence of bad habits. I was going through an old ABR report format with a new student the other day and came to the conclusion that we did not get to the point fast enough in one of our standardized conclusions. We fixed it. 20 By the way, how is that new balance-function testing report coming along? Well, let's just say that some subject matter is more resistant to strategic direction than others. When in doubt, try “The overall pattern of results is consistent with disorder of peripheral or central origin.”