Speech Therapist - Dysphagia / Swallowing Assessment Template
Speech pathology dysphagia assessment notes document comprehensive evaluations of swallowing function across oral, pharyngeal, and esophageal phases, including cranial nerve assessment, oral-motor examination, and clinical swallowing trials with various bolus consistencies to identify aspiration risk and physiological impairments.
These specialized records establish medical necessity for dysphagia intervention while providing objective documentation of swallowing safety for interprofessional teams, ensuring compliance with healthcare standards and justifying specific diet texture modifications and compensatory strategies.
They guide evidence-based treatment planning by detailing specific dysphagia characteristics, aspiration precautions, and therapeutic recommendations for safe nutritional intake, helping to prevent pulmonary complications while supporting patient dignity and quality of life through optimized feeding approaches.
Why Are Dysphagia Assessment Notes Important?
Dysphagia assessment notes facilitate critical communication between speech therapists, physicians, dietitians, and nursing staff to ensure coordinated care for patients with swallowing disorders.
These specialized notes document evidence-based assessment procedures that comply with professional standards, reimbursement requirements, and healthcare facility protocols for dysphagia management.
Comprehensive swallowing assessment documentation contributes to improved patient outcomes by enabling precise diet texture modifications, reducing aspiration risks, and guiding appropriate therapeutic interventions.
How to Write Dysphagia Assessment Notes
Begin the assessment documentation with patient demographics, relevant medical history, referral source, and specific swallowing concerns that prompted the evaluation.
Include detailed observations from clinical and instrumental assessments (FEES, VFSS), noting oral, pharyngeal, and esophageal phase abnormalities, aspiration risk, sensory function, and compensatory strategies attempted during the evaluation.
Conclude with clear diagnostic impressions, evidence-based recommendations for diet modifications using standardized terminology (IDDSI framework), therapy techniques, compensatory strategies, and specific follow-up plans.
Key Components of Dysphagia Assessment Notes
A comprehensive dysphagia assessment includes subjective history (patient complaints, medical history, nutritional status), objective measures (oral-motor examination, trial swallows with various consistencies), instrumental findings (if applicable), and functional impact on nutrition and hydration status.
The diagnostic impression section synthesizes assessment findings to identify the physiological nature of the swallowing impairment (e.g., reduced hyolaryngeal excursion, delayed pharyngeal trigger, reduced airway protection) and severity level to guide appropriate intervention planning.
Avoid generic recommendations like "soft diet" without specific IDDSI levels, vague descriptions of aspiration risk, or imprecise therapy directives that fail to address the specific physiological deficits identified during assessment.
Tips for Writing Effective Dysphagia Assessment Notes
Use standardized terminology aligned with the International Dysphagia Diet Standardisation Initiative (IDDSI) framework when documenting diet texture recommendations and include specific descriptors of swallowing physiology rather than general observations.
Ensure documentation clearly indicates informed consent procedures, patient education provided about aspiration risks, and any instances where patients may be consuming food/liquid consistencies against medical recommendations.
Implement specialized dysphagia assessment templates with dropdown menus for common impairments, rating scales for severity, and checklist features for oral-motor examination components to streamline documentation while maintaining thoroughness.
Automating Dysphagia Assessment Notes
Electronic documentation platforms with pre-programmed dysphagia assessment templates can enhance efficiency by auto-populating standard examination procedures while allowing customization for individual patient presentation.
When transitioning to automated systems, incorporate standardized terminology libraries specific to dysphagia (IDDSI framework, physiological impairment descriptors) and ensure the system allows for integration of instrumental assessment results like videofluoroscopy images or FEES recordings.
3 Common Questions About Dysphagia Assessment Notes
How detailed should my documentation be regarding specific food and liquid consistencies tested?
Document precise IDDSI levels tested during the assessment (e.g., IDDSI Level 4 - Pureed, IDDSI Level 0 - Thin Liquids), specific volumes administered, patient positioning during trials, any compensatory strategies attempted, and the exact nature of any observed dysphagia signs for each consistency.
What is the best way to document aspiration risk in my assessment notes?
Clearly specify whether aspiration was observed directly (through instrumental assessment) or inferred from clinical signs, document the specific consistencies that triggered aspiration or increased risk, note the presence or absence of a protective cough reflex, and quantify severity using standardized scales like the Penetration-Aspiration Scale when applicable.
How do I document a patient's decision to continue oral intake despite identified aspiration risk?
Document the specific risks explained to the patient, alternative feeding options discussed, the patient's demonstrated understanding of the risks (including specific language used in your explanation), any family members/caregivers present during the discussion, and the specific statement of the patient's decision with their rationale for continuing oral intake despite recommendations.
Final Thoughts on Dysphagia Assessment Notes
Thorough dysphagia assessment documentation serves as a clinical, educational, and legal record that guides safe dysphagia management, facilitates interprofessional communication, and demonstrates evidence-based clinical reasoning in swallowing disorder management.
Utilizing standardized dysphagia assessment templates that incorporate IDDSI terminology, physiological impairment descriptors, and severity rating scales can significantly improve documentation quality while ensuring comprehensive evaluation protocols are consistently followed.
Speech Therapist - Dysphagia / Swallowing Assessment
Medical and Surgical History:
• Relevant Medical Conditions:
• History of ischemic stroke 1 year ago, resulting in mild right-sided weakness and slurred speech.
• Diagnosed with gastroesophageal reflux disease (GERD), managed with proton pump inhibitors (PPIs).
• Mild cognitive impairment, affecting attention and memory, which may impact swallowing safety.
• Previous Surgeries:
• No surgeries directly related to swallowing, but patient underwent carotid artery surgery 2 years ago for stenosis, which may have impacted blood flow to the swallow mechanism.
Medications:
• Current Medications:
• Lisinopril 10 mg (for blood pressure management).
• Omeprazole 20 mg (for GERD management).
• Statin (Atorvastatin 20 mg).
• No current medications known to affect saliva production or swallowing reflex directly.
Swallowing History:
• Onset and Duration:
• Swallowing difficulties were first noticed about 4 months after the stroke, with increasing difficulty swallowing both solids and liquids.
• Initially, issues were limited to a sensation of food “sticking” in the throat, but over time, the patient began to experience occasional choking episodes and coughing while drinking liquids.
• Symptoms:
• Difficulty with both solids and liquids, but more pronounced with liquids (especially thin liquids).
• Coughing and choking during meals, particularly with liquids.
• Occasional sensation of food being stuck in the throat.
• Mild weight loss (approximately 5 pounds) over the past 3 months, not yet significant enough for concern.
• No history of recurrent pneumonia.
• Previous Swallowing Assessments/Treatments:
• A previous swallowing assessment was conducted at 6 months post-stroke, which showed mild dysphagia with liquids.
• The patient was advised to modify diet consistency to soft foods and thickened liquids but did not follow up for further treatments.
• No prior speech therapy interventions for swallowing.
Oral Intake:
• Current Diet:
• Diet is modified to a soft texture (pureed and finely chopped foods) with thickened liquids (nectar consistency).
• Patient reports eating softer foods (e.g., mashed potatoes, soups) and drinking thickened water and fruit juices.
• Swallowing Aids:
• The patient uses a commercial thickening agent to modify liquids and a special cup designed for individuals with swallowing difficulties to assist with drinking.
Clinical Swallowing Examination:
• Oral Motor Assessment:
• No facial asymmetry or drooping noted.
• Lips can seal adequately, though there is slight weakness observed with prolonged lip closure.
• Tongue shows reduced strength and coordination, with difficulty protruding and lateralizing fully. Some slurring is noted during speech.
• Dentition:
• Patient has full dentition, but teeth show mild wear due to grinding, which may slightly affect chewing efficiency. No major concerns regarding the ability to chew soft foods.
• Palatal Function:
• Velar movement and closure are symmetric. However, there is slight delay in the soft palate elevation during swallowing, which could contribute to mild nasal regurgitation during some trials.
• Pharyngeal Reflexes:
• Gag reflex is present but reduced in intensity on the right side, possibly linked to the right-sided weakness post-stroke.
• Palatal reflex is symmetric.
• Saliva Management:
• The patient is able to manage oral secretions adequately but reports occasional pooling of saliva in the mouth, particularly when fatigued.
• Trial Swallows:
• Solid foods (pureed) swallowed with minimal difficulty, no evidence of aspiration or residue noted.
• Liquid swallows (nectar thickened) resulted in mild coughing and throat clearing, suggesting possible mild aspiration. No overt aspiration was noted during the assessment.
Instrumental Assessment:
• Videofluoroscopic Swallow Study (VFSS):
• Key findings:
• Bolus control is generally intact, though a slight delay in initiation of the swallow is noted for both solids and liquids.
• Mild aspiration was observed with thin liquids, which was not observed with thickened liquids.
• There is mild residue noted in the valleculae and pyriform sinuses following solid swallows, but patient is able to clear it with a second swallow.
• Timing of the pharyngeal phase appears slightly delayed, with some residue left in the oral cavity, likely due to reduced tongue strength.
Assessment Findings:
• Oral Phase Dysphagia:
• Mild difficulty in initiating the swallow with liquids. Reduced tongue strength noted during the oral prep phase. No significant concerns with chewing or bolus preparation.
• Pharyngeal Phase Dysphagia:
• Mild delay in swallow initiation. Occasional mild aspiration during liquid swallows. Some residue in the pharyngeal cavity following solid food swallows, but generally able to clear it.
• Esophageal Phase:
• Not assessed via VFSS as no significant esophageal symptoms are reported. No signs of esophageal dysphagia observed during clinical assessment.
Recommendations:
• Dietary Recommendations:
• Continue with soft, moist foods and thickened liquids (nectar consistency).
• Gradually attempt to introduce slightly thinner liquids under careful monitoring.
• Encourage small, frequent meals to reduce the risk of aspiration.
• Therapeutic Interventions:
• Begin speech therapy targeting oral motor strength and coordination exercises, focusing on improving tongue strength and range of motion.
• Postural adjustments during swallowing (chin tuck or head turn techniques) to reduce the risk of aspiration, especially with thin liquids.
• Swallowing exercises to improve bolus transit and decrease residue.
• Further Assessments:
• Consider referral to a gastroenterologist for evaluation of esophageal motility if symptoms of reflux or difficulty with solids persist.
• Follow-up VFSS or FEES to monitor changes over time.
Plan:
• Treatment Goals:
• Short-term: Improve oral motor strength and swallowing safety for liquids, reduce coughing and choking episodes.
• Long-term: Ensure safe swallowing of thin liquids and expand diet textures to include more solid foods, improve oral hygiene and saliva management.
• Follow-up Schedule:
• Initial follow-up in 2 weeks for reassessment of swallowing function. Regular therapy sessions to continue bi-weekly, with potential re-evaluation of VFSS in 3-6 months.
This comprehensive assessment outlines the patient’s current swallowing difficulties, treatment recommendations, and therapeutic plan, offering a structured approach for improving swallowing safety and function.
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