Swallowing Treatment Note (Dysphagia)

Patient Identifiers

(Keep sections concise. Use objective descriptors and frequency counts. If information is not available or not assessed, write "Not assessed" or "Unavailable" rather than leaving blank.)

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Date of Service: [Service date]

Clinician: [Name, credentials]

Location/Setting: [Inpatient unit / Outpatient clinic / SNF / Home health]

Current Diet Order: [as ordered in chart]

Current SLP Recommendation: [current recommendation] (If different from the active order, document who was notified and the outcome.)

Feeding Route: [PO / tube / mixed]

Reason for Skilled Visit: [airway protection training / diet advancement trial / compensatory strategy training / swallow exercise program / caregiver education]

Relevant Diagnoses: [dysphagia type and contributing medical conditions]

Safety & Readiness

• Alertness/Participation: [Level of arousal, ability to follow directions, endurance]
• Positioning: [Upright at ~90°: yes / no] (If no, specify current angle and rationale.)
• Respiratory/Airway Status: [Room air / O2 device + flow; SpO2; trach/cuff status; secretion burden]
• Oral Status: [Dentition; oral hygiene; xerostomia; mucosal integrity]
• PO Trials Today: [yes / no]
  • (If no, state reason: [NPO order / insufficient alertness / respiratory instability / patient refusal / other]. Document the skilled intervention provided instead.)

Subjective

[Brief patient or caregiver report on swallowing since last visit: coughing/choking episodes with frequency, problem consistencies, diet tolerance, use of strategies at meals, home exercise adherence, interval events impacting swallow safety.] (If report unavailable due to communication barriers or caregiver absence, note succinctly.)

Objective

(Document only clinician-delivered skilled interventions and observed responses. Use IDDSI level numbers + names for consistencies. Use frequency counts, e.g., "cough 1/6". Do not document "aspiration" as confirmed unless supported by instrumental assessment; instead use "clinical signs concerning for aspiration" and list the observed signs.)

• PO Trials: (Only if performed)
  • Consistency: [IDDSI level number + name]
  • Delivery Method: [utensil / cup / straw / teaspoon / syringe] [self-fed / clinician-fed] [volume per trial]
  • Strategies Applied: [chin tuck / small sips / double swallow / effortful swallow / supraglottic swallow / pacing / other]
  • Cueing Level: [independent / verbal cues / tactile cues] [min / mod / max]
  • Objective Signs: [cough x/x; throat clear x/x; wet vocal quality x/x; multiple swallows x/x; oral residue x/x; delayed initiation; increased WOB; SpO2 change]
  • Outcome: [tolerated / tolerated with strategies / not tolerated]

  (Repeat per tested consistency.)

• Compensatory Strategy Training: [Strategy name] for [problem targeted]; [accuracy %, independence level, cueing required] (Only if performed)
• Rehabilitative Exercises: [Exercise name]; [sets × reps, hold times, resistance]; [accuracy %, fatigue level, patient response] (Only if performed)
• Education/Caregiver Training: [Audience] on [topics covered]; [method]; teach-back [accurate / needs reinforcement] (Only if performed)

Assessment

[Clinical impression of swallow safety and efficiency based on today's session.] (Specify which consistencies were best tolerated and under what conditions. Summarize progress toward goals using measurable data. Provide a concise skilled rationale for SLP services today. Note barriers or risks such as cognition, fatigue, respiratory status, or limited caregiver support.)

Plan

(This section serves as the explicit swallow safety recommendations for the care team and must be complete and unambiguous.)

• Diet Recommendation: [IDDSI level number + name for solids] / [IDDSI level number + name for liquids]
• Medication Administration: [whole / crushed in puree / with liquid wash / per pharmacy]
• Supervision Level: [independent / supervision / 1:1 assist] (Note alertness requirements.)
• Positioning: [upright during meals; remain upright for X minutes after intake]
• Priority Strategies: [list top 3–5 in order of application]
• Oral Care: [frequency and key steps] (Emphasize timing relative to meals if aspiration risk present.)
• Hold Criteria: [when to stop PO and notify RN/MD: persistent cough, wet voice, respiratory distress, fever, significant SpO2 drop, lethargy]
• Next Steps: [continue current plan / trial next consistency / recommend VFSS or FEES / coordinate with team]
• Treatment Time: [total minutes]

(If SLP recommendation differs from the current diet order, document communication to reconcile: who was contacted, when, and outcome.)

Signature

Clinician Signature/Credentials: [Name, credentials]

Date/Time: [Signature date/time]