Dysphagia Clinical Notes

Here's are some guidelines that i've used to structure my clinical notes. I've found that putting 'impression' and 'recommendations' as headings has helped other professionals understand my notes.

SLT medical notes structure

Date and Time and Profession (Speech and Language Therapist written out in full)

Subjective (i.e. heard/read)

Reason for referral/review. Pt seen for assessment of swallow, Nursing Staff and medical notes report patient coughing during meals.

If initial assessment; brief summary from medical notes, including any previous SLT input, and current status.

If review: current swallow status. NS report pt managing current recommendations with no concerns.

Consent.

Pt’s response to assessment. Pt asleep, roused easily to voice.

Objective (i.e. seen/done)

Positioning

If initial assessment: Oral assessment: cover; dentition, oral hygiene, oro motor function, i.e. cranial Nerve assessment, CN V, VII, X, XII

Oral trials;

pre-oral stage; comment on feeding

oral stage; comment on lip closure, anterior-posterior transfer, residue, oral hygiene

pharyngeal stage; comment on swallow trigger, hyolaryngeal function, penetration/aspiration

Communication; receptive, expressive, cognition, functional

Discussed with patient/family/therapists/doctor/nurse.

If review: swallow not reviewed because, e.g. discussed with NS, report managing well.

Analysis – impression and recommendations

Impression;

Swallow: diagnosis and severity and characterised by, e.g. mild oral and moderate pharyngeal dysphagia, characterised by weak and slow swallow trigger

indication of risk of aspiration

change from baseline / change from last session

Communication

Recommendations (nb shorter for review or refer to previous ax and full recs)

• Positioning
• Consistencies – food and fluid
• Compensatory techniques – e.g. pace / cutlery / bolus size
• Monitor for signs of aspiration, e.g. coughing
• Symptoms to look out for, e.g. stop if coughing
• Contact SLT and put NBM if signs of aspiration
• Mouth care
• Medications
• Non oral feeding, if appropriate