Episode 67: Elements of Excellent Dysphagia Documentation: The Clinical Swallow Evaluation with Kelsey Day, MS, CCC-SLP
Kelsey Day joins Leigh Ann to discuss the crucial elements of dysphagia documentation, focusing on the Clinical Swallow Evaluation. Dysphagia documentation need not only reflect skilled service, but should also contribute new, valuable information to the medical team and guide future dysphagia care. Our documentation should demonstrate “whole picture” understanding of our patient’s goals, values, rehabilitation potential, personal risk factors for dysphagia-related complication, and more. Our discussion covers the importance of thorough documentation and provides a case study.
topics covered:
Elements of good dysphagia documentation
Why is our dysphagia documentation important?
Basic elements of a clinical swallow evaluation
Case study to illustrate clinical swallow evaluation documentation
Brief discussion on resources available for people to improve their clinical documentation skills
Kelsey’s Clinical Swallow Evaluation (CSE) Process
PRE CSE:
Medical record review. You're going to make a whole picture recommendation at the end of your CSE, so you have to start with a whole picture understanding of the patient. Be a detective! Start with establishing chronic vs acute symptoms.
Identify predisposing dysphagia risk factors, those are chronic conditions that put your patient at risk for potential chronic dysphagia.
Examples: stroke history, history of TBI, Myasthenia Gravis, ALS, HNC, radiation therapy, etc.
Clinical signs of possible chronic dysphagia: unintentional weight loss, recurrent pneumonias, self-restriction or modified diets
Identify precipitating dysphagia risk factors: things that have happened recently to the patient (ex. this hospitalization or brand new symptoms).
Examples: acute stroke, respiratory failure that required endotracheal intubation, sepsis, critical illness myopathy, tachypnea (even just patients who are working harder to breathe, their respiratory rate itself could be a precipitating dysphagia risk factor), the medications that they're on, the high flow nasal canula. There's so many different things.
DURING CSE:
Interview the patient.
Start with open ended questions.
Follow up with closed or Yes/No questions to confirm information, because sometimes the information we receive from patients can be inconsistent or unclear.
Some patients cannot participate in the interview. So then we direct our questions to the patient's caregiver if they're available.
Gather the subjective information.
What's the patient's level of alertness?
What is the patient's work of breathing at the time of your exam?
What's their pain that could impact your findings?
And what are their cognitive communication skills for participating in your exam?
Complete a cranial nerve exam.
I'm going to be evaluating cranial nerves 5, 7, 9, 10, and 12.
Observe the oral structure.
Complete a laryngeal function exam.
Determine patient's secretion management:
Is the oral cavity dry, or do they have congested, wet upper airway sounds?
Is the patient coughing and throat clearing on their secretions? Are they drooling? Are they bringing up mucus?
Determine vocal quality on their maximum phonation time.
Capture S to Z ratio.
Comment on their pitch range.
Assess cough function.
If my patient’s cough is perceptually weak, and I can already identify that this patient is going to be on my caseload, then I'll bring out a peak flow meter or an expiratory pressure device because I'll know we will need to be using this in therapy. I'll get an objective measure on their cough strength.
PO trials. I administer the P.O. trials necessary to determine the need for an instrumental exam.
Determine need for FEES vs. VFSS
I’m looking at the probable underlying etiologies, and how could it be best assessed. And if I'm thinking that probably my patient has laryngeal dysfunction, either from extubation or from a surgery, then the best exam might be FEES, at least first to assess laryngeal function directly.
POST CSE:
Write the report. Combine elements of the chart review, patient interview, and CSE with the following format.
Describe presence or absence of clinical signs of acute or chronic dysphagia.
Include the presence or absence of precipitating dysphagia risk factors.
Include the indications for instrumentation and rationale.
Include a statement of the patient's personal risk factors for developing a dysphagia related pulmonary complication. Consider the patient's oral hygiene, their immune function, their physical mobility and their cough strength to make a presumption about the safety to continue an oral diet prior to the instrumentation (or be NPO).
Kelsey’s “Recommendations” Format for documenting after a Clinical Swallow Evaluation:
Instrumentation recommended: FEES, VFSS or both.
Diet rec for patient until instrumentation is complete.
Strategies to reduce pulmonary related complications (oral hygiene, suctioning, increasing mobility, etc.)
Specialist referrals if needed (GI, neurology, dietitian, etc.)
Treatment recommendations (often “pending results of instrumentation” at this stage)
Continuing care recommendations: i.e. follow-up with outpatient SLP. At this stage, it’s often “pending results of instrumentation.
Thank you, Kelsey!!
*Edited for the show notes by Leigh Ann from Kelsey’s presentation in the podcast episode.
Kelsey Day, M.S., CCC-SLP is a medical Speech-Language Pathologist with seven years of experience in the acute care setting. As a graduate of Northwestern University, she was trained in dysphagia diagnostics and videofluoroscopy by Dr. Jerilyn Logemann. Kelsey now serves as the lead SLP at California Hospital Medical Center, a trauma and stroke center in downtown Los Angeles, where she supervises and mentors a team of nine SLPs. She specializes in dysphagia care for the critically-ill, multi-trauma, and tracheostomy/ventilator-dependent populations. Kelsey launched the FEES program at her hospital to facilitate early swallow intervention for the mechanically-ventilated population. She currently serves as a mentor for the Medical SLP Collective, teaches continuing education courses in medical speech pathology, and guest lectures at California State University, Fullerton.
If you found this episode helpful, you might also like to listen to part 2 of Kelsey’s talk:
And you might find these other resources useful:
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