Speech-Language Pathology Consult Note (Acute Care)

Date/Time of Service: [Date and time]

Clinician: [Name, credentials (e.g., MS, CCC-SLP)]

Location: [Unit/Room]

Encounter Type: [Consult / Initial Evaluation / Re-evaluation]

Interpreter Used: [Yes: language, modality / No / Not applicable]

Referral and Consult Question

[Referring provider/service and reason for referral] (Explicitly state the consult question(s) and relevant timing context such as post-op day, hours since extubation, or onset timing. If the consult question was not specified, state that the evaluation was performed based on chart review and bedside presentation, and document the clinical focus.)

Clinical Snapshot

[Single-sentence summary: age range, admitting diagnosis/primary event, and key SLP-relevant risk factors (e.g., intubation duration, tracheostomy/vent status, neurologic event, encephalopathy, head/neck surgery, pulmonary compromise)]

Chart Review and Pertinent History

• [Admitting diagnosis and brief hospital course relevant to SLP focus]
• [Pertinent comorbidities relevant to swallowing/communication/cognition (e.g., prior stroke, dementia, Parkinson's disease, COPD, head/neck cancer, GERD)]
• [Pertinent procedures with dates (e.g., intubation/extubation, trach placement, surgeries)]
• [Medications impacting mentation/secretions/swallow (e.g., sedatives, anticholinergics, opioids)]
• Baseline Function: [Prior diet texture and liquid level, feeding independence, typical medication administration, communication mode, cognitive status/living situation, prior SLP history or instrumental studies] (If baseline is unknown despite attempts to obtain it, state "Baseline unknown" and note sources attempted.)

Pre-Assessment Status

• Alertness/Participation: [Alert / lethargic / fluctuating; ability to follow commands]
• Respiratory Status: [Room air vs O2 delivery method/settings; work of breathing]
• Airway/Lines/Tubes: [Trach type/size and cuff status; NG/OG/PEG; relevant lines]
• Positioning: [HOB restrictions, spine/hip precautions, tolerated position]
• Factors Limiting Assessment: [Pain, agitation, language barrier, medical instability, or none]

(For each item, distinguish between "not assessed," "unable to assess" with reason, and "not applicable." Omit items that do not apply.)

Subjective

[Patient/caregiver-reported swallowing symptoms, communication concerns, and relevant preferences or goals] (Include only if the patient or surrogate can contribute. Use brief direct quotes for high-salience complaints. If the patient cannot participate and no collateral is available, omit this section entirely and ensure the reason is documented in Pre-Assessment Status.)

Objective Evaluation

Procedures Performed: [Clinical swallow evaluation / Speech-language evaluation / Cognitive-communication screen / Voice assessment / Tracheostomy communication evaluation]

Patient Positioning During Assessment: [Position and HOB angle]

Communication/Cognition Findings

(Include domains assessed; omit domains not evaluated.)

• Hearing/Vision: [WNL / mild / moderate / severe impairment] (Include functional impact on participation.)
• Motor Speech: [Features of dysarthria/apraxia, intelligibility descriptor, rate, prosody] [WNL / mild / moderate / severe]
• Language – Comprehension: [Auditory/reading comprehension level, command following] [WNL / mild / moderate / severe]
• Language – Expression: [Spoken/written expression, naming, fluency, word-finding] [WNL / mild / moderate / severe]
• Voice: [Quality, loudness, pitch, endurance] [WNL / mild / moderate / severe]
• Cognitive-Communication: [Orientation, attention, memory, executive function, safety awareness, insight] [WNL / mild / moderate / severe]
• Functional Communication: [Ability to express needs, use call light, provide consent, communicate pain] (State assistance level and reliability.)
• AAC Supports Trialed: [Type(s) trialed and effectiveness] (Include if applicable.)

Oral Mechanism Examination

(Include when dysphagia or dysarthria is in scope.)

• Dentition/Oral Hygiene: [Description including denture fit/function if applicable]
• Labial Function: [Seal, ROM, strength, coordination]
• Lingual Function: [ROM, strength, coordination]
• Palatal Function: [Movement/symmetry]
• Secretion Management: [Pooling, drooling, need for suction]
• Cough/Throat Clear: [Volitional and reflexive strength/effectiveness]

Clinical Swallowing Evaluation

(Include when dysphagia is the consult indication. Do not infer safety for consistencies not tested.)

• Pre-PO Readiness: [Alertness/participation, positioning, oral care status, baseline vocal quality]
• Trials by Consistency: (Repeat for each consistency actually tested; omit those not trialed.)
  • [IDDSI level and bolus type]: [Delivery method/volume; oral phase findings; pharyngeal signs (cough, wet voice, respiratory changes); strategies trialed and response; assistance level; tolerance/efficiency concerns]
• Testing Course: [Trials completed as planned / Trials stopped early: reason]

Tracheostomy/Ventilator Considerations

(Omit this section entirely if no artificial airway.)

• Trach Type/Size: [If known]
• Cuff Status During Assessment: [Inflated / Deflated; who managed cuff]
• Speaking Valve/Cap Trial: [Placed / Not placed; tolerance; voice quality; secretion management; vitals response]
• Contraindications/Barriers Encountered: [Air trapping, increased WOB, desaturation, secretions, or none]

Assessment

(Begin by directly answering the consult question(s). Use hedged language appropriate to bedside findings, such as "clinical signs consistent with" or "suspected," and do not assert aspiration physiology or silent aspiration without instrumental evidence.)

• Diagnostic Impression: [Concise statement of suspected impairments relevant to swallowing/communication/cognition with severity]
• Functional Impact: [What the patient can/cannot safely or effectively do; contextual factors]
• Risk Statement: [Aspiration/choking risk; nutrition/hydration adequacy; pulmonary considerations]
• Limitations: [What cannot be determined without instrumental assessment; confounding factors (e.g., alertness, respiratory status, language barrier)]
• Prognosis: [Favorable / Guarded / Uncertain with brief rationale] (Include if relevant to medical course.)

Recommendations

Diet and Liquids

(Include when dysphagia is in scope.)

• Diet Texture: [IDDSI Level and description]
• Liquids: [IDDSI Level and description]
• Medication Administration: [Whole / Crushed in puree / Via tube / Other]
• Supervision/Assistance: [Independent / Setup / Close supervision / 1:1 assist]
• Positioning: [Upright angle and duration; aspiration precautions]
• Compensatory Strategies: [Pacing, small sips/bites, alternate solids/liquids, effortful swallow, chin tuck, head turn] (Include only strategies recommended.)
• Oral Care: [Frequency and approach]
• Hold PO and Re-consult SLP if: [New/worsening cough with PO; wet/gurgly voice; increased O2 needs; fever/respiratory changes; acute mental status change]

Instrumental Assessment

• Indicated: [Yes – VFSS/MBSS / Yes – FEES / Not indicated at this time]
• Diagnostic Question(s): [Physiologic or safety/efficiency questions to answer]
• Timing Priority: [Urgent (same day) / Soon (24–48h) / Routine]

Communication/Cognition Supports

• Staff Strategies: [Simplified language, extra processing time, written supports, verify understanding]
• AAC: [Device/board placement, access method, training needs]
• Safety Supervision: [Level tied to cognitive status and functional communication]
• Referrals: [Neuropsychology / OT / PT / Audiology / ENT / Other] (If applicable.)

Discharge Planning

• SLP Follow-up Setting: [Inpatient rehab / SNF / Home health / Outpatient / None]
• Caregiver Training Needs: [Topics and timing]
• Diet Continuity Instructions: [Carry-over of IDDSI levels/strategies across transitions]

Eating and Drinking with Acknowledged Risks

(Include only when patient/surrogate chooses oral intake despite documented risk. Frame as shared decision-making with risk mitigation, not SLP clearance.)

• Decision Context: [Goals of care / Comfort-focused care / Patient preference]
• Decision-Maker: [Patient with capacity / Surrogate / Team consensus]
• Options Discussed: [NPO with alternative nutrition/hydration vs oral intake options]
• Risks Explained: [Aspiration pneumonia, choking, malnutrition/dehydration]
• Agreed Risk Mitigation: [Diet/liquid level, strategies, supervision, positioning, oral care]
• Plan for Review: [When and how to reassess decision]

Plan of Care

(Include when SLP will provide ongoing services. If this is a one-time consult, state "No further acute SLP needs at this time" with re-consult criteria and omit remaining bullets.)

• Frequency: [e.g., daily / x times per week while inpatient]
• Treatment Focus: [Swallow safety/efficiency; communication; cognitive-communication; trach communication; voice; AAC training]
• Short-Term Functional Goals:
  • [Goal 1 with measurable functional target]
  • [Goal 2 with measurable functional target]
• Discharge Criteria: [Medical stability, goal attainment, transition of care]

Education and Coordination

• Education Provided To: [Patient / Family / Nursing / Provider / Dietary / RT]
• Topics Covered: [Diagnosis, risks, strategies, diet recommendations, device use, safety]
• Response/Understanding: [Verbalized understanding / Demonstrated via teach-back / Declined]
• Team Notification: [Who was informed of key recommendations and orders placed]

Attestation

Clinician Signature: [Name, credentials]

Date/Time Signed: [Date and time]