Clinical Swallow Evaluation Note (Bedside)

Date/Time: [Date and time of evaluation]

Patient: [Patient name and identifiers per facility convention]

Location: [Unit/bed or setting]

Referring Provider: [Name, title]

Reason for Consult: [Referral trigger/clinical question]

Clinician: [SLP name, credentials]

Reason for Evaluation

[Reason for evaluation narrative] (Compose 2–4 sentences beginning with the referral trigger, including timing/onset, current feeding status [NPO / PO], and patient goals if available. If history is limited, state why.)

Pertinent History

• [Diagnoses impacting swallow safety/efficiency] (Include only items that change clinical risk or recommendations.)
• [Prior dysphagia history and instrumental study results with dates] (Include FEES/MBSS outcomes if known.)
• [Relevant surgeries/procedures] (Intubation duration, tracheostomy status, head/neck surgeries or radiation.)
• [Current respiratory support] (Device and settings; e.g., room air, nasal cannula, HFNC, NIV, mechanical ventilation.)
• [Medications with swallow relevance] (Sedatives, anticholinergics/xerostomia-inducing agents, neuromuscular agents.)

Current Status and Readiness for Trials

• Alertness/Command Following: [Level of arousal and ability to follow commands] (If unable to assess, document "Unable to assess" with reason.)
• Positioning: [Upright in chair / Upright in bed / Semi-upright / Unable to achieve upright] (Include angle if available.)
• Respiratory Status: [O2 delivery and settings, SpO2 if monitored, work of breathing] (If not monitored, state "Not monitored".)
• Tracheostomy/Cuff/Speaking Valve: [No trach / Trach in place, cuff inflated/deflated, speaking valve status] (If not applicable, state "N/A".)
• Oral Status: [Dentition/dentures, oral hygiene, secretions/xerostomia] (Note factors impacting oral control or safety.)
• Current Diet Order: [NPO / PO with IDDSI level and facility label] (If unknown, document as "Unknown" and attempt to verify.)
• Decision re PO Trials: [Proceeded with trials / Trials deferred due to [reason]] (If deferred, skip to Clinical Impression.)

Oral Mechanism Examination

• Lips/Face: [Symmetry, seal, sensation] (Normal vs abnormal with brief descriptors.)
• Jaw: [Range of motion, strength, stability] (Normal vs abnormal.)
• Tongue: [Bulk, ROM, strength, coordination] (Normal vs abnormal.)
• Velum: [Elevation with phonation, nasal emission] (Normal vs abnormal; if unable to assess, state reason.)
• Dentition/Dentures: [Adequate / poor / edentulous / dentures fit] (Note functional impact.)
• Oral Mucosa/Secretions: [Moist / dry / pooling / thick secretions] (Note suction need if present.)

Voice, Cough, and Secretion Management

• Baseline Vocal Quality: [Clear / wet / gurgly / hoarse / breathy / aphonic]
• Volitional Cough: [Strong / moderate / weak / absent] (Note effectiveness to clear suspected material.)
• Throat Clear Ability: [Effective / partially effective / ineffective / unable]
• Secretions at Rest: [Managed independently / drooling / pooling / requires suction]

PO Trials

Trial Setup: [Position], [self-fed / clinician-fed], [utensils], [bolus sizes], [compensatory strategies trialed]

Consistencies Attempted: [List IDDSI levels and names tested; e.g., Thin liquid (IDDSI 0), Puree (IDDSI 4), Soft & Bite-Sized (IDDSI 6)]

[Consistency name and IDDSI level]: [Oral phase observations: bolus control, mastication, transit, residue] [Swallow initiation: timely / mild delay / moderate delay / severe delay] [Post-swallow signs: cough, throat clear, wet voice, multiple swallows, patient-reported sensation, or no overt signs] [Effect of strategies if trialed] [Reason for stopping if applicable] (Repeat for each consistency tested.)

If Trials Deferred: Trials deferred due to [reason]. [Interim recommendations and plan for reassessment or instrumental study.]

Clinical Impression

[Interpretive summary of bedside findings] (State whether there is suspected dysphagia or no clinical concern observed. Specify suspected phase involvement [oral / pharyngeal / possible esophageal] with appropriate uncertainty. Comment on aspiration risk based on overt clinical signs; explicitly state that silent aspiration cannot be excluded on bedside exam. Note efficiency concerns and contributing factors. Use cautious, non-definitive language—avoid claims about definitive airway protection or absence of aspiration.)

Recommendations

Diet/Liquid: [Recommended IDDSI texture and liquid level with facility label], [positioning during and after meals], [supervision level], [pacing strategies], [utensil restrictions if applicable]

Medications: [Whole / crushed in puree / via tube] (Note to verify with pharmacy if crushing is recommended.)

Aspiration Precautions: [Oral care frequency], [feeding strategies], [signs to monitor], [who to notify if concerns arise]

Instrumental Assessment: [FEES / MBSS / Not indicated at this time] (Provide rationale for modality selection and list specific clinical questions to answer.)

Treatment: [Recommended therapy frequency], [initial targets], [education provided and patient/caregiver response] (Include only if dysphagia therapy recommended.)

Referrals: [ENT / GI / Dietitian / Other with brief rationale] (Include only if indicated.)

Risk Acceptance Discussion: [Discussion summary, stated preferences, participants, and resulting plan] (Include only if patient/family accepts known aspiration risk or refuses recommended restrictions.)

This bedside evaluation reflects clinical observations without visualization of pharyngeal/laryngeal structures. Silent aspiration cannot be ruled out without instrumental assessment.