Episode 69: Elements of Excellent Dysphagia Documentation: Instrumentation and Treatment with Kelsey Day, MS, CCC-SLP
“Dysphasia diagnostics aren’t only about aspiration.
It’s also about how efficient is my patient’s swallow, and are they also at risk for malnutrition or dehydration”
Kelsey Day joins Leigh Ann to discuss the crucial elements of dysphagia documentation, from Clinical Swallow Evaluation (in part one) to instrumentation to treatment. 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 several case studies.
topics covered:
Format of FEES report with case study
Format of VFSS report with case study
Format of treatment note with case study
Kelsey’s Format for report writing following FEES/VFSS:
Subjective statement. Comment on the patient's level of alertness, their cognitive communication skills to be able to participate in the exam, their pain and their work of breathing.
Objective information
Note the trials administered, and the type of respiratory support our patients are on.
FEES: report on nasopharyngeal endoscopic findings. Comment on the secretions on the pharyngeal wall, contraction, and non swallow tasks like in an effortful pitch glide, vocal fold motion, and any anatomic findings.
Comment on the oral and pharyngeal physiology. Following the components of the MBSimp is recommended. Under FEES, some of these need to be inferred. So, for example, I might not be able to directly see the base of tongue retraction or the UES relaxation on FEES, but some inferences can be made about those.
Report on compensatory strategies trialed. List all compensatory strategies trialed and then comment on the efficacy of those strategies.
Include the 8 point Penetration Aspiration Scale or PAS. Include the PA scale for each consistency that was trialed. My preference is to report on the worst outcome per consistency.
And then I include the DOSS or the Dysphasia Outcome and Severity Scale.
Impression section: The overall diagnosis and your interpretation from the FEES/VFSS.
State the dysphasia diagnosis in terms of both the severity (mild, moderate, severe), according to the DOSS, and then also the classification: Is it just oral phase? Is it pharyngeal phase? Is it oropharyngeal? Or is it pharyngoesophageal?
I also like to comment on the etiology if it's known. So for many patients, it could be multifactorial, related to both acute and chronic dysphagia risk factors.
Include a prognostic statement, if that's known, which probably can't be known unless you know the etiology.
And then I include a statement of both the swallow safety and the efficiency. A statement on the patient's personal risk factors for developing a dysphagia related pulmonary or nutrition/hydration complication.
Recommendations from the instrumental.
Diet recommendation
Strategies to reduce the risk for dysphagia related pulmonary complication, like oral hygiene and increasing physical mobility, things that are within our patient's control.
Specialist referrals.
Treatment recommendations
Continuing Care recommendations
Thank you, Kelsey!!
*Edited for the show notes by Leigh Ann from Kelsey’s transcript
Resources mentioned in the episode:
Karen H. O’Neil, MA, Mary Purdy, PhD, Janice Falk, MA, and Lanelle Gallo, MS. The Dysphagia Outcome and Severity Scale. Dysphagia 14:139-145 (1999).
John C. Rosenbek, PhD, Jo Anne Robbins, PhD, Ellen B. Roecker, PhD, Jame L. Coyle, MA, and Jennifer L. Wood, MS. A Penetration-Aspiration Scale. Dysphagia 11: 93-98 (1996).
Martin-Harris B, Brodsky MB, Michel Y, et al. MBS measurement tool for swallow impairment--MBSImp: establishing a standard. Dysphagia. 2008;23(4):392–405. doi:10.1007/s00455-008-9185-9
*Tips to access journal articles behind paywalls: Use Google Scholar to find full versions of articles. Another route is to ask your library to use “interlibrary loan” to access journal articles. Emailing the principle author (their email is typically included in the abstracts) for a copy for your personal use. If affordable, you could buy the article from the publisher.
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, check out Part 1 of Kelsey’s talk here:
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