Download RESULTS RIGHT EAR PASS REFER LEFT EAR PASS

PHILIPPINE ACADEMY OF NEUROTOLOGY, OTOLOGY &
RELATED SCIENCES
A Study Group of the Philippine Society of Otolaryngology-Head & Neck Surgery
NEWBORN HEARING SCREENING OTOACOUSTIC EMISSION REPORT
Name of Patient
Date of Birth
Mothers Name
Home Address
Attending Physician
Case No
Gender
Contact No
( ) In-Patient ( )Out-Patient
RESULTS
RIGHT EAR
LEFT EAR
PASS
PASS
REFER
REFER
IMPRESSION
PASS (OAE detected)
An Otoacoustic Emission (OAE) test was performed on your child. A “PASS” means that a normal
response was recorded from your child’s ears. This response is consistent with a normal peripheral
hearing levels. No further testing is recommended at this time. However, continuous monitoring of your
child’s hearing and speech development should be conducted throughout the first few years of life.
REFER (OAE not detected)
An Otoacoustic Emission (OAE) test was performed on your child. A “REFER” means that a normal
response could not be recorded from one or both of your child’s ears. This could be due to a high noise
level in the nursery/room, an active baby or vernix/wax in the ear canal at the time of test or presence of
hearing loss. Your child should be re-tested within three months.
RECOMMENDATION
No further testing is required at this time, retest only if hearing loss is
suspected.
(Patient did not pass audiologic screening.) Follow-up audiologic testing within 3
months.
Suggest a more diagnostic test, e.g. auditory brainstem response (ABR).
Suggest ENT referral for ear/otoscopic evaluation.
Date of Test __________________
Audiometrist __________________