Newborn Hearing Screening Checklist For Completed Training: Competency
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1Newborn Hearing Screening Check List for Completed Training:
Competency
Name_____________________________________
Date___________________
Newborn Hearing Screening Program Director:
TASK
√
Date
Read and Review Newborn Hearing Screening Policy, Procedure and Protocols
Understand contact to NHS Coordinator and/or Bio-Med
Preparation
Obtain Daily Birth Census
Prioritize Daily Screenings
Enter birth census information into Logbook
Screening
Enter Room/remove baby from room at appropriate times (i.e. after baby has been fed (or
after circumcision for males), check with nurse, etc)
Set up baby for screening
Complete screening
as trained for site (equipment training checklist)
1
Completed Screen (1x or 2x depending on results)
Print out hearing screening results
Attach printout to appropriate paperwork (pass, refer)
Complete appropriate paperwork for completed hearing screening (pass, refer, waive, etc)
•
Pass form: given to parent when baby passes BOTH ears (up to 2 screens)
•
Follow-up Refer form: given when baby refers in one or both ears TWICE- MUST
BE SIGNED BY PARENT AND BY SCREENER
•
Waiver form: signed by parent at time they choose to waive
•
Missed form: sent home to baby after discharge with a missed hearing screen
Explain results to parents/caregivers and hand them completed paperwork (or give
paperwork to nurse to give to parents- NICU only- in which case nurse signs paperwork as
well)
IF BABY REFERS TWICE
•
Counsel parents on follow-up options
•
If applicable, fax refer results to appropriate audiology diagnostic clinic
•
Contact EHDI if further support is needed
Documentation
Enter demographic information, hearing screening results, and any other remarkable
information into birth log on EVERY baby born in Birth Facility:
•
Demographic Information for baby and mother
•
First Screening results
•
Second Screening results (if necessary)
•
Baby’s status: transferred out, transferred in, demise, waived, missed, risk factors,
etc
•
Document YOUR name as the person completing screening- do NOT input
someone else’s name
•
INITIAL and DATE any and all logged information
____________________________________
________________________________
Hearing Screener Signature
Date
Newborn Hearing Coordinator Date
Rev. 8/09 C. Sperry
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