Report Writing

Front 1

Report Writing: Subjective

Back 1

Subjective: include age, level of care (where they are living and how much assistance they need), medical hisotr, pt. complaint (include quaotes), medical concerns, and what they're being referred for

Front 2

Report Writing: Subjective (Example)

Back 2

Pt is a 76 year old male living at independent level of care. Med hx = Parkinson's Disease, COPD, and GERD. Pt. c/o food "sticking in throat." MD concerend w/ aspiration/dysphagia

Front 3

Report Writing: Objective

Back 3

Objective: includes what was done. Some clinicians include the phases here. I include then in the "A" section. Include views (lateral or AP) and textures tried

Front 4

Report Writing: Objective (Example)

Back 4

Modified Barium Swallow Study completed in conjuction with the Radiology Dept. Pt. seeated in upright position (90 degress) and viewed in the lateral and AP positons. Textures trials includedL thin liquids, neture thick liquids, pureed, wet-soft, dry-soft, dry-crumbly, and tablet

Front 5

Report Writing: Assessment

Back 5

Asessment: includes phases of swallowing here. Include the deficits. Make sure you discuss "cause and effect" and strategies/positioning that worked. That’s the "meat" of all of this

Front 6

Report Writing: Plan

Back 6

Plan: include what your plan is. What are your recommendations? Make sure you include: 1. diet recommendations (both solids and liquids) 2. swallow therapy recommenations (mention duration and frequency of therapy) 3. strategies (chin tuck, repeat swallow, ... and do it in the order of how strategies should be done) 4. other specialty recommendations (GI, UGI, voice eval) 5. Goals

Front 7

Report Writing: Plan (Example)

Back 7

1. Diet: pureed with netar liquids 2. swallow tx 3x a week for 2 weeks 3. straegies A. small bits/sips B. chin tucks with liquids C. hard swallow D. repeat/extra swallows E. alternate solids with liquids F. periodic throat clearing 4. Recommend: GI consult

Front 8

Report Writing: Plan (Example)

Back 8

Goal: A. Pt will verbalize and demonstrate his swallow safety strategies w/out visual cues at 80% accuracy. B. Pt. will show no pharyngeal red flags while performing his strategies. C. Pt will report no episodes of "choking" while outside the clinic while performing his strategies D. Pt's diet will safely be upgraded to Mechanical soft w/ thin liquids by the end of therapy. E. Video ape of MBS will be reviewed w/ Pt and spouse for education