FEES Report (Swallowing Endoscopy)

Patient Name: [Patient name] MRN: [MRN] DOB: [DOB] Sex: [Male / Female / Intersex / Unknown]

Location: [Unit/bed or clinic]

Date of Exam: [Date] Time: [Start–End or duration]

Exam Type: [FEES / FEESST]

Referring Provider: [Name, credentials] Treating Service: [Service]

Endoscopist: [Name, credentials]

Video/Photo Recorded: [Yes / No] (Include recording consent status if applicable.)

Reason for Referral

[Clinical concern prompting FEES and specific clinical questions to be answered] (Limit to 1–3 sentences. Do not duplicate full medical history.)

Relevant Background

• Pertinent diagnoses/events: [Key conditions with onset/event dates] (Include neurologic events, head/neck surgery, intubation duration, radiation history as relevant.)
• Current diet/liquid (IDDSI): [IDDSI solids level] and [IDDSI liquid level] (If NPO or tube feeding, specify type and route.)
• Respiratory status: [Room air / O2 delivery device and flow / Ventilator settings] [Baseline SpO2 if relevant]
• Exam validity factors: [Alertness, ability to follow commands, communication barriers, positioning limitations, fatigue] (Note factors that may limit interpretation.)
• Other pertinent history: [Additional relevant medical/surgical/medication factors] (Only include if directly relevant.)

(If key background information is unavailable, document "Not available at time of exam" rather than leaving blank.)

Consent and Safety

• Informed consent: [Obtained / Not obtained] from [Patient / Legal representative] (Include recording consent if applicable.)
• Contraindications/precautions considered: [Bleeding risk / Anticoagulation / Nasal obstruction / Agitation / Recent epistaxis / Facial trauma / None / Other]
• Monitoring: [Pulse oximetry in place / Not used] [Baseline vitals if monitored]
• Baseline positioning: [Upright degree, bed/chair type] (Note if this reflects typical mealtime posture.)
• Suction availability: [Confirmed / Not available]

Procedure Details

• Scope passage: [Right / Left] nare; [Easy / Moderate / Difficult] passage; patient tolerance [Good / Fair / Poor]
• Topical agents: [None / Anesthetic / Decongestant / Both] (Note potential impact on laryngeal/pharyngeal sensation.)
• Bolus coloring method: [Food dye color / Natural contrast / None]
• Sensory testing (if FEESST): [Method and air pulse thresholds / Not performed]
• Complications: [None / Epistaxis / Vasovagal symptoms / Laryngospasm / Desaturation / Patient refusal / Other] (If present, describe event, actions taken, and outcome.)
• Exam status: [Completed as planned / Aborted early] (If aborted, document partial findings obtained and explicit limitations.)

Baseline Endoscopic Observations (Pre-Bolus)

• Nasopharynx/Velopharyngeal function: [Within normal limits / Impaired: description] (Note closure during phonation and dry swallow.)
• Base of tongue and pharynx: [Within normal limits / Impaired: description] (Note symmetry, atrophy, edema, erythema.)
• Hypopharynx: [Within normal limits / Impaired: description] (Note pooling, structural lesions.)
• Larynx/Vocal folds: [Within normal limits / Impaired: description] (Note vocal fold mobility, closure, edema, secretions at baseline.)
• Functional tasks: [Phonation / Breath hold / Cough / Throat clear] with airway protection [Adequate / Reduced / Absent]
• Visualization limitations: [None / Area not visualized and reason]

Secretion Management

• Location/volume/consistency: [Location(s): valleculae / pyriforms / laryngeal vestibule / trachea]; [None / Trace / Mild / Moderate / Severe]; [Thin / Ropey / Frothy]
• Patient awareness/response: [Spontaneous swallows / Prompted swallows / Cough / Throat clear / No response]
• Suctioning: [Not needed / Required] with response [Effective / Ineffective]
• Standardized secretion rating: [Scale used and score with interpretation]

(Explicitly tie NPO or major diet restriction recommendations to secretion findings and protective responses.)

Swallow Trials

(Repeat the following block for each consistency tested. For major consistency categories not tested, document "Not tested" with reason.)

Consistency: [Consistency name] (IDDSI [Level])

• Volumes: [Specific volumes or range]
• Delivery method: [Teaspoon / Cup / Straw / Syringe] [Self-fed / Clinician-fed]
• Posture/position: [Neutral / Chin tuck / Head turn / Head tilt / Reclined / Other]
• Strategy in place: [None / Specific maneuver or modification]
• Safety observations:
  • [No penetration or aspiration / Penetration / Aspiration]; Timing: [Before / During / After] swallow; Depth: [Shallow / Deep / Below vocal folds]; Patient response: [Spontaneous cough / Cough with cue / No response]; Outcome: [Expelled / Partially expelled / Not expelled]
  • PAS score: [Score] - [Descriptor]
  • (During white-out, aspiration cannot be directly visualized. If inferred, explicitly state basis—e.g., material observed below vocal folds after swallow, reflexive cough with subglottic residue.)
• Residue:
  • Location(s): [Valleculae / Pyriform sinuses / Posterior pharyngeal wall / Laryngeal vestibule]
  • Severity: [None / Trace / Mild / Moderate / Severe]; [Residue scale and score if used]
  • Clearance: [Spontaneously cleared / Cleared with cue / Cleared with liquid wash / Did not clear]
  • Status after best clearance attempt: [None / Trace / Mild / Moderate / Severe]
• Additional notes: [Fatigue pattern, coordination issues, respiratory-swallow incoordination] (Only include if observed.)

Consistencies Not Tested

[Thin liquids / Thick liquids / Purees / Solids]: Not tested due to [Safety concern / Patient refusal / Fatigue / Time constraint / Other]. (Omit section if all major consistencies were tested.)

Compensatory Strategies Tested

(List each strategy tested, its effect, and recommendation status. Only recommend strategies demonstrated effective during FEES that patient can perform consistently.)

• Strategy: [Postural adjustment / Swallow maneuver / Bolus modification / External support]
  • Applied with: [Consistencies/trials tested]
  • Effect on airway invasion: [Eliminated / Reduced / Unchanged / Worse]
  • Effect on residue: [Reduced / Unchanged / Worse]
  • Patient ability: [Independent / With minimal cues / With maximal cues / Unable]
  • Recommendation: [Recommend for mealtimes / Recommend as therapy target / Not recommended]

Interpretation

• Overall swallow status: [Within functional limits / Dysphagia: Mild / Moderate / Severe]
• Primary physiologic impairments (safety): [Reduced airway closure / Delayed swallow initiation / Poor secretion management / Other]
• Primary physiologic impairments (efficiency): [Reduced pharyngeal constriction / Reduced BOT retraction / UES dysfunction / Other]
• Aspiration risk: [Specific consistencies and conditions associated with risk tied to observed findings]
• Contributing factors: [Alertness / Fatigue / Respiratory status / Structural findings / Medication effects / Positioning constraints]
• Study limitations: [Limited consistencies / Limited trial count / Poor tolerance / Severe secretions / Positioning constraints / Inability to follow commands] (Avoid absolute statements; prefer "No aspiration observed during tested trials of [specific consistencies].")

Recommendations

Diet and Liquid

• Solids (IDDSI): [Level] Liquids (IDDSI): [Level]
• NPO status: [N/A / NPO with allowances: ice chips / oral care sips / none; oral care plan]
• Risk discussion: [N/A / Risk-benefit discussed with patient/caregiver/team regarding PO intake with acknowledged risk or pleasure feeds; required safeguards documented]

Mealtime Strategies

• Positioning: [Upright degree] during intake; remain upright [Duration] post-meal
• Supervision/assistance: [Independent / Supervision / 1:1 assist / Total assist]
• Bolus control strategies: [Small bites/sips / Slow rate / Alternating solids and liquids / Double swallow / Check oral clearance / Cueing as needed]
• Oral care: [Frequency and method] (Emphasize when aspiration risk present.)
• Medication administration: [Whole / Crushed in puree / Liquid form / Via tube]

Therapy and Follow-Up

• Skilled dysphagia therapy: [Recommended / Not recommended]; Focus: [Secretion management / Airway closure / Timing / Strengthening / Maneuver training]
• Referrals: [ENT / GI / Pulmonology / Dietitian / None] with indication
• Repeat instrumental assessment: [Not indicated / FEES / VFSS] in [Timeframe] for [Rationale]

Education Provided

• Recipient(s): [Patient / Family / Nursing / Dietary]
• Method: [Verbal / Written materials / Video review of study]
• Teach-back understanding: [Adequate / Partial / Not demonstrated]
• Refusals: [None / Exam refused / Recommendations refused]; Immediate safety plan: [Details]

Attestation

Clinician Signature: [Name, credentials]

Date/Time Signed: [Date and time]

(General instructions: Document "Unknown" or "Not available" for required but unavailable information rather than leaving blank. Pair standardized rating scales with brief narrative descriptors. Distinguish clearly between directly observed findings and inferred conclusions, particularly regarding aspiration during white-out.)