Hearing screening performed on [Date] for [Patient Name], [Date of Birth], [Medical Record Number].  Patient presented for [reason for visit; e.g., well-child check, annual physical, concerns about hearing loss].  Otoscopic examination revealed [describe tympanic membrane appearance; e.g., normal bilateral tympanic membranes, erythematous right tympanic membrane, presence of cerumen].  Hearing acuity assessed using [method of screening; e.g., pure-tone audiometry, otoacoustic emissions, behavioral audiometry].  Results indicated [screening results; e.g., pass bilateral, refer right ear, refer bilateral].  If referred, recommendations for follow-up audiological evaluation provided.  Patient andor guardian counseled on findings and next steps.  Diagnosis: Hearing screening [specify laterality and result; e.g., bilateral pass, right ear refer, bilateral refer].  ICD-10 code: Z01.10 (Encounter for hearing examination following failed hearing screening) or Z01.11 (Encounter for hearing examination following passed hearing screening) as applicable.  CPT codes may include 92551 (Pure tone audiometry air only) or 92587 (Comprehensive audiometry threshold evaluation and speech recognition) depending on the complexity of testing, if billable.  Differential diagnoses considered, if applicable, may include conductive hearing loss, sensorineural hearing loss, or mixed hearing loss.  Plan: [Outline plan; e.g., return for well child check in 6 months, referral to audiology for complete evaluation, return to clinic if symptoms worsen].