Dysphagia / Swallowing

Dysphagia concerns swallowing function and can involve medical and nutritional risk. A clinical evaluation can document reported symptoms, oral observations, intake, and response to existing strategies; bedside observations alone cannot confirm or rule out aspiration. The SLP coordinates assessment and care with the relevant medical and interdisciplinary team, using instrumental findings when indicated.

What to consider in assessment

Review the medical history, current orders, nutrition and hydration context, reported symptoms, and relevant instrumental findings. A clinical swallow evaluation can describe observed signs and response to trials, but bedside observation alone cannot confirm or rule out aspiration. Instrumental assessment may be indicated to answer specific physiologic questions.

What the SLP can address

The SLP evaluates swallowing within their competence and the care setting, coordinates with the medical team, and documents response to an established plan. Diet and strategy decisions depend on the full clinical picture and, when appropriate, instrumental findings.

Within the prescribed plan, observe a functional meal or specified trials, record consistency and amount, and practice an established strategy. Monitor comfort, fatigue, and the person’s ability to use the strategy; coordinate any change with the responsible team.

• Record precisely what consistency and amount were presented and which signs were observed.
• Distinguish a reported symptom from a direct observation and from an instrumental finding.
• Follow the established care plan; do not infer a new diet recommendation from a checkbox.

Choose strategies using assessment findings, the person’s preferences, and the treatment context.

Specify the functional context, observable response, criterion, support level, and how progress will be checked.

Separate patient report, observable coughing or voice changes, and instrumental findings. Do not write “aspirated” based only on a cough. Record the exact consistency, volume, timing, assistance, and response without inventing a diet recommendation.

• S: Document reported swallowing changes, symptoms, and current intake.
• O: Identify consistencies, amounts, observations, and prescribed strategies used.
• A and P: Interpret in the context of full assessment and team recommendations; coughing alone does not establish aspiration.

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