Documentation of Whisper Test Results
Document the whisper test as "passed" or "failed" (not "positive" or "negative"), as this reflects the functional outcome of the hearing screening test.
Proper Documentation Terminology
The whisper test is a functional hearing screening examination, and its results should be documented using pass/fail terminology rather than positive/negative terminology. This approach aligns with how screening tests for sensory function are typically documented in clinical practice.
Why "Passed" or "Failed" is Preferred
- Functional assessment clarity: The whisper test evaluates whether a patient can hear whispered speech at a specific distance, making it a functional pass/fail assessment rather than a diagnostic test that detects the presence or absence of disease 1
- Avoids confusion: Using "positive" terminology could be ambiguous—does "positive" mean the patient heard the whisper (good outcome) or that hearing loss was detected (abnormal finding)? 1
- Consistency with screening methodology: The Centers for Disease Control and Prevention emphasizes that screening tests should be documented in ways that clearly communicate the clinical outcome and next steps 2
Recommended Documentation Format
Document as follows:
- "Whisper test: Passed" - Patient correctly repeated whispered words at appropriate distance
- "Whisper test: Failed" - Patient unable to correctly repeat whispered words, indicating potential hearing impairment requiring further evaluation 1
Additional Documentation Elements
Include these details in your documentation 1:
- Distance tested (typically 2 feet/60 cm from the ear)
- Which ear(s) tested (right, left, or bilateral)
- Specific words or phrases used
- Whether the non-tested ear was adequately masked
- Any factors that might affect reliability (ambient noise, patient cooperation, language barriers)
Clinical Context and Follow-up
- If the test is passed: No immediate audiologic intervention needed, though consider patient's clinical context and symptoms 1
- If the test is failed: Refer for formal audiologic evaluation with pure-tone audiometry to quantify hearing loss and determine etiology 1
- Document the clinical decision: Note why the whisper test was performed and what action will be taken based on results 1
Common Pitfalls to Avoid
- Don't use "positive/negative" terminology as this creates ambiguity about whether you're describing test performance or disease detection 1
- Don't document without specifying which ear was tested, as unilateral hearing loss requires different management 1
- Don't rely solely on patient self-reporting of hearing ability without objective documentation of the screening test performance 2
- Ensure proper technique: The whisper test requires specific methodology (proper distance, adequate masking of opposite ear, appropriate whispered intensity) to be valid 1