Audiolog learns a trade by learning how that trade writes: the words it uses, the documents it produces, and the things it must never claim. These sixteen are built and tested. Every example below is drawn from real output, not a mock-up.
Audiology and hearing aid dispensing
Writes: Clinical record · GP letter · Patient letter · Recommendations
Knows: Air–bone gap, tympanometry types, speech audiometry, red-flag referral wording, BSA and NHS report style
You say
“Mr Sample, blocked right ear, microsuction, cleared, advice given.”
You get back
Otoscopy before and after, the method used, consent recorded, aftercare advice, and a referral line only where it is indicated.
Alarm, emergency lighting and extinguisher servicing
Writes: Visit record · Defects and observations · Customer email · Quote request · To confirm
Knows: Loop and device addresses, manual call points, unwanted fire signals, defects against observations, the responsible person, BS 5839-1 and BS 5266-1
You say
“Panel kept gannin into fault, traced it to a detector, proper clarty. Log book’s got nowt in it since March.”
You get back
Site, system, work carried out, findings, parts fitted, status on leaving, and a customer email in plain English. The dialect never reaches the record.
Occupational health surveillance
Writes: Health record · Employee letter · Employer summary · Actions · To confirm
Knows: HSE categories, warning and referral levels, baseline and periodic audiometry, exposure action values, hearing protection and fit testing
You say
“Reference BE-118, press shop, ringing in the left ear, otoscopy clear, I’ll do the categories back at the office.”
You get back
The employer copy carries fitness and actions only, never clinical detail. If the practitioner has not set a category, the record says so rather than guessing one.
First-opinion small animal practice
Writes: Clinical record · Owner summary · Medicines · Referral · To confirm
Knows: SOAP, BAR and QAR, body condition score, cranial cruciate ligament, otitis externa, POM-V, estimate rather than quote
You say
“Gave him the usual dose of the anti-inflammatory and sent home the drops he had last time.”
You get back
“Anti-inflammatory given [dose not stated]” and a question back to the vet for the name, the dose and the weight. It will not invent millilitres.
Musculoskeletal clinics
Writes: Clinical note · GP letter · Patient summary · Exercise sheet · To confirm
Knows: Range of movement in degrees, Oxford power grades, painful arc, empty can and Hawkins-Kennedy tests, red flags, home exercise programme
You say
“Ran out of time so I didn’t measure the range properly. Gave her a couple of glute exercises.”
You get back
Measurements left as [not stated], exercises listed with [dosage not stated], and the missing pieces raised as questions.
UK chiropractic clinics
Writes: Clinical record · Patient summary · Exercise sheet · GP letter · To confirm
Knows: Case history, working diagnosis or rationale for care, plan of care, adjustment and mobilisation, Kemp’s and Spurling’s tests, cauda equina red flags
You say
“She asked how many treatments she’ll need. I said I’d know more after the first couple.”
You get back
No course of care invented, no consent recorded that was not described, and the General Chiropractic Council’s own wording throughout.
UK osteopathic practices
Writes: Clinical record · Patient summary · Exercise sheet · GP letter · To confirm
Knows: Working diagnosis, HVT and HVLA, muscle energy technique, articulation, somatic dysfunction and the TART criteria, segmental levels
You say
“Did some articulation through the thoracic spine and soft tissue work either side.”
You get back
Articulation stays articulation. It will not upgrade it to a thrust, and it will not invent the segmental level you didn’t say.
Podiatry and chiropody clinics
Writes: Clinical record · Patient summary · Plan and advice · GP letter · To confirm
Knows: Callus and heloma, debridement, onychocryptosis, partial nail avulsion with phenol, monofilament and pedal pulses, NICE diabetic foot risk categories
You say
“Didn’t have the Doppler with me, so the vascular side isn’t done. Getting her back before I say where she sits.”
You get back
The risk category is left unassigned and raised as a question. It never writes that pulses were palpable when nobody checked them.
Independent optical practices
Writes: Sight test record · Prescription · Patient advice · Referral · To confirm
Knows: R and L, unaided vision against aided acuity, LogMAR and Snellen kept apart, cover test, phoria against tropia, IOP with its method and time, cup-to-disc ratio
You say
“Couldn’t get a view of the back of the eye, and the pressures machine was playing up.”
You get back
No prescription figure invented, no disc described that was never seen, and the referral urgency left to you.
Aesthetic and cosmetic clinics
Writes: Treatment record · Aftercare · Consent · Review · To confirm
Knows: Toxin brands whose units never convert, HA fillers in millilitres, batch number and expiry, glabella and lateral canthal lines, vascular occlusion, hyaluronidase
You say
“Same as last time, the usual dose across the glabella and the crow’s feet.”
You get back
“[dose not stated]”, “batch number [not stated]”, and a separate line each for prescriber and injector — because in this trade that distinction is a legal one.
Counselling and psychotherapy practices
Writes: Session record · Risk note · Client summary · Supervision · To confirm
Knows: Client not patient, presenting issue not diagnosis, formulation, and risk graded exactly: ideation, intent, plan and means never collapsed into one another
You say
“Didn’t push on what that meant today, she was distressed and we were nearly out of time.”
You get back
The risk note reads “No risk or safeguarding content in these notes.” It will never write that risk was assessed, and the record comes back shorter than the notes, not longer.
Community and social care OT
Writes: Assessment · Equipment · Client summary · Referral · To confirm
Knows: Occupation as a life not a job, personal and domestic ADLs, transfers, moving and handling, and equipment named exactly — a grab rail is not a banister rail
You say
“Will look at chair raisers next time once I know the chair measurements.”
You get back
No measurement invented, no equipment added, and single- or double-handed care left undecided — because that one word sets the cost of somebody’s care package.
Adult and paediatric SLT
Writes: Clinical record · Mealtime plan · Family summary · Referral · To confirm
Knows: The IDDSI framework by number and name, aspiration against penetration, bedside against instrumental assessment, and a delay that must never become a disorder
You say
“She’s on thickened drinks at the moment. I’ll decide about the level after I’ve seen her again.”
You get back
“[IDDSI level not stated]” and a question. A swallowing level is an instruction a care home then follows at every meal, so it is never guessed and never dropped.
UK acupuncture clinics
Writes: Case note · Treatment record · Client summary · Advice · To confirm
Knows: Points written as given — GB20, LI4, Yintang — de qi, retention time, moxa and cupping, and the two traditions kept apart
You say
“She asked whether acupuncture would sort the headaches out.”
You get back
The question recorded, not answered. No point invented, no needle count guessed, and no claim about what acupuncture does.
Assessors, not servicing engineers
Writes: Assessment · Findings and actions · Persons at risk · Client letter · To confirm
Knows: Responsible person, relevant persons, significant findings, Type 1 to 4, compartmentation, stay put against simultaneous evacuation, and the Fire Safety Order’s own phrasing
You say
“I want to come back with access before I put a rating on this one.”
You get back
No risk rating, no priority, no evacuation strategy. What you couldn’t get into is recorded as exactly that, rather than quietly marked satisfactory.
Letting agents and inventory clerks
Writes: Property record · Condition · Meters and keys · Agent summary · To confirm
Knows: Inventory against schedule of condition, the cleanliness standards that are not interchangeable, meter serials and readings, and fair wear and tear left to the adjudicator
You say
“Meter cupboard was blocked by boxes so no readings today.”
You get back
No reading invented and no room invented. One sentence of notes produces one room, not a furnished house — and who pays is never the report’s call.
The same three checks run on every trade, because a made-up figure in your records is your problem, not ours.
Anything missing comes back as [not stated] and a short list of questions, never as a plausible guess.
A check compares the finished note with your words and flags anything that was added: a number, a side, a condition, a claim that something was done.
If something is flagged, it is sent back for correction before you ever see it. Whatever is left is shown to you in one line above your documents.
Building a trade takes about a week: the terms it must use, the documents it must produce, and the words it must never write. What takes longer is the part that matters — someone who does that job for a living checking twenty notes before it goes anywhere near a real record. That is the gate, and we do not skip it.
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