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8 Cards in this Set

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Report Writing: Subjective
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
Report Writing: Subjective (Example)
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
Report Writing: Objective
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
Report Writing: Objective (Example)
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
Report Writing: Assessment
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
Report Writing: Plan
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
Report Writing: Plan (Example)
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
Report Writing: Plan (Example)
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