Report Writing and Medical Referral Guide
OVERVIEW
Components of the medical report should outline the overall justification of medical necessity and skilled services used to render diagnosis. The American Speech-Language-Hearing Association (ASHA) audiology practice portal outlines key issues and components in the documentation of audiology services. Specifically, ASHA determines that clinicians must (1) use understandable terminology to reflect advanced skillset/knowledge, (2) provide the rationale for type/complexity of test/procedure, and (3) document results and outcomes with professional interpretations in a timely fashion and error-free.
Additionally, clinicians must ensure patient/family/caregiver participation and understanding of diagnosis, plan, and realistic expectations. Documentation should indicate any counseling or education provided as well as patient/caregiver response. Clarification should be given for any decision modifying the noted plan. Finally, the documentation should outline when discharge or inclusion in a rehabilitation program is appropriate.
The key components to include in the encounter (ASHA, n.d.):
• Date of encounter
• Reason for referral (including order)
• Case history
• Procedure(s) performed
• Patient/family/caregiver participation
• Subjective and objective data
• Clinical interpretations/diagnosis
• Recommendations
• Accommodations and modifications to protocol/procedures
• Patient and family/caregiver counseling and education
• Credentials and signature of clinician
CLINICAL IMPRESSIONS
Medical history, case history, and test findings should all be considered closely when writing the impressions and making recommendations. As stated by Shepard and Telian (1996, pp. 160), “the patient’s presenting history may be as influential in shaping the impressions as the results themselves.” The impressions section summary may include an overall statement as to whether or not the vestibular examination was normal or abnormal. The rest of the impression section may detail the clinical findings and provide supporting statements for the overall cause of the patient symptoms and signs. These supporting statements should relate back to the specific objective and subjective evidence from the clinical examination, and when applicable evidence from the scientific literature. Some caution is needed interpreting findings in isolation of the patient’s presenting history and the remaining portions of the vestibular examination, which may result in confusion and possible management delays (Shepard & Telian, 1996).
Questions to keep in mind when writing the clinical impressions:
1. Are the patient symptoms and signs related to a vestibular disorder/dysfunction? If so, clarify which disorder. If not vestibular in nature, present support of evidence for your rationale.
2. Is there indication of peripheral vestibular system involvement? Provide supportive evidence for localization to right or left side-of-lesion if possible. If a peripheral lesion is not suggested, then a general statement may be added to the report such as “no objective indications of peripheral vestibular system involvement.”
3. If a peripheral lesion is suggested, is it compensated or uncompensated (see following section on compensation)?
4. Is there indication for BPPV? If yes, identify involved ear/semicircular canal and provide supportive evidence. Was a treatment maneuver performed at the time of testing? If yes, specify type and number of repetitions. After treatment, was residual nystagmus or symptomatology noted? Was the patient provided with home therapy instructions?
5. Are there indications of central vestibulo-ocular or oculomotor system involvement? Provide supportive evidence and localize origin if possible.
7. Is the patient at risk of falling? What evidence from the clinical examination, case history, or medical history supports this claim?
8. Are there other possible causes for the patient reported symptoms? Dizziness and imbalance often have multifactorial causes that may not be explained based solely on a neurotologic condition. The impression section may include possible reasons for ruling in or out other considerations for dizziness based on patient supportive history. See Appendix A for other possible considerations.
9. Are there unexplained findings that warrant further investigation? Shepard and Telian (1996) recommend that the vestibular report include statements that prompt the clinician to further investigate unexplained findings or refer to another specialist, if applicable and necessary.
Review of Vestibular Compensation
Vestibular compensation naturally occurs after most vestibular insults and is the basis for vestibular and balance rehabilitation therapy. Stages of compensation are activated due to asymmetrical differences in neural activity progressing from static to dynamic. The compensation process requires neuronal change in the cerebellum and brainstem nuclei in response to sensory conflicts produced by central and peripheral vestibular pathology (Barin, 2021).
• Static
○ Symptoms: vertigo, nausea, possible vomiting, imbalance, tilting of head and body to the side of lesion
○ Signs:
■ Direction fixed spontaneous nystagmus (enhanced without fixation)
■ Direction fixed gaze stability nystagmus (enhanced without fixation) that follows Alexander’s law
■ Ocular tilt reaction (OTR): skew deviation, head tilt, ocular counterrolling toward lesion side; subjective visual vertical (SVV) toward the lesion side
■ Caloric unilateral weakness
■ Directional preponderance on caloric irrigation testing with pattern consistent with spontaneous nystagmus
■ Abnormally reduced video head impulse test (VHIT) gain with corrective saccades
■ Sinusoidal harmonic acceleration (SHA) rotational chair reduced VOR gain with increased phase lead, and asymmetry pattern consistent with spontaneous nystagmus
■ Impaired ocular and/or cervical vestibular evoked myogenic potentials (VEMPs) in a pattern dependent upon involved organs/branches of vestibular nerve
Note: It is important to keep in mind that during the early phase of static compensation, reduced vestibular responses may be observed on both the lesion and contralesion sides due to cerebellar clamping. This may result in “false” bilateral hypofunction responses.
• Dynamic:
○ Symptoms: dizziness, vertigo, imbalance and/or blurred vision provoked with head and body movements
○ Signs:
■ Abnormal performance on dynamic visual acuity testing (DVAT)
■ Post-head shake nystagmus
■ Improved rotational chair SHA parameters of phase and VOR gain, but asymmetries consistent with previous spontaneous nystagmus
■ Abnormal postural control, which is a sign that the patient has not completed functional compensation; patients may demonstrate impaired performance on condition 4 of the modified clinical test of sensory interaction on balance (MCTSIB) and conditions 5 and 6 of the sensory organization test (SOT) of computerized dynamic posturography
Note: Clinical signs of peripheral vestibular dysfunction (e.g., caloric unilateral weakness, reduced VHIT gain, abnormal VEMP responses) are apparent even during the dynamic compensation phase; however, presence of additional corrective saccades may be indicated during VHIT testing.
RECOMMENDATIONS
“An informed patient, along with judicious selection of medical, surgical, and/or rehabilitative measures, will result in a positive outcome in most causes of vestibular dysfunction, even if symptoms cannot be entirely eliminated.” (Shepard & Telian, 1996, pp. 191)
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