Modified Barium Swallow Study Report (VFSS/MBSS)

(Include only fields with available information; omit any unavailable fields entirely.)
Patient Name: [Patient full name]
MRN: [Medical record number]
Date of Birth: [DOB]
Sex: [Sex]
Patient Location: [Inpatient unit / Outpatient clinic / ED / Other]
Study Date/Time: [Date and time of study]
Referring Provider: [Referring provider name and credentials]
Ordering Indication: [Ordering indication text]
Performing Clinician(s): [Names and roles, e.g., SLP, Radiologist, Technologist]
Prior Comparison Studies: [Prior VFSS/MBSS with dates]

Indication

[Chief swallow concern in patient-centered language] [Specific clinical question to be answered] [Current nutrition route and baseline diet using IDDSI terminology] (If baseline intake is unknown, state "baseline diet unknown." Compose 2–4 concise sentences.)

Relevant History

(Include only if high-yield contextual factors are known; omit section entirely if none apply.)

• [Neurologic disease or acute neurologic event]
• [Head/neck cancer history and treatment]
• [Airway history, e.g., tracheostomy, recent intubation/extubation]
• [Prior aspiration pneumonia or recurrent respiratory infections]
• [Surgical history altering swallowing anatomy]
• [Current respiratory status and oxygen requirements]
• [Cognitive/behavioral factors affecting strategy carryover]

Pre-Study Status

(Include only when abnormal or when it limits study validity; omit section if normal.)

• [Alertness/participation level]
• [Positioning achieved, e.g., lateral/AP feasibility, seating constraints]
• [Feeding method: self-fed / clinician-fed]
• [Adverse events during exam]
• [Early termination and reason]

Technique

• Views obtained: [lateral / AP / both]
• Contrast materials: [Barium type and preparation method]
• Consistencies tested: [IDDSI levels and names, e.g., IDDSI 0 Thin, IDDSI 2 Mildly Thick, IDDSI 4 Pureed, IDDSI 7 Regular]
• Volumes/delivery: [Teaspoon, cup sip, straw sip, sequential swallows with approximate volumes]
• Esophageal screening: [performed / not performed] (If performed, note brief method.)
• Fluoroscopy dose: [Time and dose metrics if captured]
• Protocol modifications: [Deviations and rationale] (Omit if standard protocol followed.)

Findings

(Add one row per tested condition. Document only findings relevant to interpretation; omit normal subsystems unless clinically significant.)

Condition	Oral Phase	Pharyngeal Phase	Airway Invasion
[Consistency: IDDSI level and name] [Volume/delivery method] [Strategy applied, if any]	[Bolus control, premature spillage, oral transit, oral residue location/severity]	[Swallow initiation timing, hyolaryngeal excursion, laryngeal vestibule closure, pharyngeal constriction, PES opening, pharyngeal residue location/severity]	[Penetration/aspiration: present / absent] [Timing: before / during / after swallow] [Response: none / cough effective / cough ineffective / throat clear] [PAS score] (if used)

(Duplicate rows for each additional tested condition.)

Untested Conditions: [Consistencies not tested and reason, e.g., deferred due to aspiration risk, patient intolerance] (Omit if all planned consistencies were tested.)

Esophageal Screen: [Screening-level observations] (Include only if esophageal screening was performed and findings were notable.)

Strategies Tested

(Omit section entirely if no strategies were tested.)

• [Strategy/maneuver/posture name]:
  • Conditions tested: [Consistency, volume, delivery]
  • Effect: [Change in penetration/aspiration and/or residue]
  • Reliability: [Patient ability to perform strategy consistently]

Impression

• [Swallow safety summary: what penetrates/aspirates, under which conditions, silent vs. with response]
• [Swallow efficiency summary: residue patterns and functional impact]
• [Primary physiologic impairments explaining observed events]
• [Strategy effectiveness summary]
• [Study limitations] (Include only if limitations constrain interpretation.)
• [Standardized scores: worst PAS with condition, MBSImP totals, DIGEST grade] (Include only scores used at facility.)

Recommendations

Diet: [Liquid level (IDDSI) and solid level (IDDSI); if NPO, specify any limited oral trial allowances and required safeguards; pair with local diet names if required by facility]

Mealtime Strategies: [Positioning; bolus size/pacing; supervision level: independent / setup assist / 1:1 supervision / total assist; compensatory postures or maneuvers]

Medications: [Administration method, e.g., whole with specified IDDSI level, crushed in puree, liquid formulation]

Oral Care: [Oral hygiene recommendations] (Include when aspiration risk is present.)

Therapy: [Targeted interventions tied to observed impairments, e.g., airway protection training, exercises for hyolaryngeal excursion]

Referrals: [GI for esophageal concerns / ENT for structural evaluation / Nutrition / Pulmonology] (Include only if indicated.)

Follow-up: [Timing or triggering conditions for repeat instrumental study]

(Use IDDSI terminology consistently. Do not generalize beyond tested conditions. Esophageal observations are screening-level only; recommend dedicated esophageal evaluation for concerning findings.)