All Write: A Review of Clinical Writing for Dysphagia Diagnostics
Author: Heather Bolan, MA, CCC-SLP
Edited by: Ainsley Martin, MS, CCC-SLP
Name of Course: Clinical Writing for Dysphagia Diagnostics
Instructor: Kelsey Day, M.S., CCC-SLP, hosted by Mobile Dysphagia Diagnostics
Cost: $300
Number of CEUs Earned: 0.8 CEUs
Format: Live lecture format (via webinar due to COVID-19) with writing workshops for CSE, VFSS, and FEES
Duration: One day
Subject: Clinical dysphagia documentation
Level of Difficulty: Intermediate
Applicable Patients/Disorders: This course is applicable for medical SLPs in a variety of settings who evaluate and treat patients with a variety of dysphagia based disorders such as: COPD, PNA, dysphagia-related intubation, CHF, lung CA, encephalopathy, tachypnea, penetrating neck injury, head and neck CA, esophageal dysphagia, chiari malformation, malnutrition, dehydration, TBI, CVA, ACDF, CHF (to name a few).
Content: Dysphagia assessments by speech-language pathologists (SLPs) are the cornerstone of quality of care for patients with dysphagia. However, SLPs have historically been misunderstood or unheard possibly due to inefficient format, unclear terminology, or because of a lack of strong clinical documentation. Utilizing language that all healthcare providers can understand will inevitably lead to consistent care, improved quality of care, and buy-in from our colleagues. Kelsey has carefully crafted a course to teach the medical SLP how to talk the talk and walk the walk that will leave your physicians wowed by your craft!
Usefulness of Resources: Resources provided in this course included Kelsey’s templates for the CSE, VFSS, and FEES, 100 sample CSE reports (yeah, I said 100), 25 sample VFSS reports, and 25 sample FEES reports. In addition, Kelsey also includes commonly utilized scales (such as the PAS, DOSS, Yale Pharyngeal Residue Severity Rating Scale, and Murray Secretion Scale), commonly accepted medical abbreviations glossary, and Kelsey’s carefully constructed ‘phraseology’ utilized in her everyday writing. She gives you every resource you could possibly need to succeed.
“Dysphagia present at bedside. Pt coughed on 3/7 presentations of thin liquid. No other PO administered. Recommend NPO.”
…. Have you ever read a dysphagia assessment like this and felt like you had more questions than answers (or if you’re like me wondering what even happened in that eval)?? We learn so much of our skill on the job, yet excellent medical documentation is often lacking in the field of SLP. We continue to be misunderstood as a profession and our knowledge is often underutilized. If you’re left wondering why you aren’t getting those dysphagia referrals from your medical team, maybe it’s time you reassess how effectively you’re communicating with your team. It’s time that SLPs sharpen our clinical documentation skills and get the respect we deserve.
But, why should we care about effective documentation?
Man, did Kelsey hit this out of the park! It’s easy for us as SLPs to get laser focused on using 'speech phrasing.' In reality, this is a very complex answer and one that is critical for us to understand. Have you ever thought about being sued for malpractice? That never really hit home for me until my hospital offered for us to attend a malpractice lawsuit mock case. The “lawyers” asked a variety of questions ranging from our highest level of education, to what was the exact time that X happened. The kicker was, the clinical professionals had to answer questions from a patient they had seven years prior! All they had to rely on was their documentation. From a legal standpoint, Kelsey covered exactly WHY we should care so much. Documentation is also how we reflect the skill of the services we provide to the non-SLPs often reviewing our documentation.
Quality of Care
Helps us track a patient's progress or decline over time in relation to our interventions.
Communicate care with other providers and help organizes the provider’s care
Serves as our findings/impressions for the medical team.
Reimbursement
Medicare requires that our treatments are reasonable, necessary, specific/functional, effective, and skilled (1).
Poor documentation can significantly alter our patient’s ability to receive services and for therapists to see reimbursement.
Risk Management (this is HUGE!)
Solid documentation is legal protection for both the patient AND provider. Failure to document can breach our patient’s standard of care and the Patient Self-Determination Act of 1990. .
These MUST be kept in mind when documenting risk-benefit analysis of dysphagia treatment options.
Informed Consent and Refusal
Too often, I see healthcare professionals documenting that a patient “refused” a plan of care or is “noncompliant” without being formally educated. The healthcare professional very well could have spent a half hour discussing treatment options with that patient, but it wasn’t documented.
We must make sure that consent and refusals are patient choices (2). Treatment alternatives, risks, and benefits of evaluation and treatments MUST be covered and documented. Discussion and the patient’s response should be clearly documented in the EMR.
Remember that just because a patient refuses the “safest” recommended diet does NOT mean they are disqualified from dysphagia treatments. Our views may differ and that is OK! We are here to help the patient achieve their goals for care, not impose our personal beliefs.
Ethics
As ASHA discusses in their code of ethics, we are required to adequately maintain and appropriately secure records of our patients, and ONLY allow access when authorized or required by law (3).
Now that we have an understanding why our clinical is so important, let's get into the actual report writing…
The Clinical Swallow Evaluation (CSE)
The clinical swallow evaluation (CSE) allows us to make valuable hypotheses on swallow pathophysiology and impairments, assess the need for instrumental and referrals, and prepare you for the questions you want to be answered by an instrumental. However, SLPs are highly variable in their utilization of assessment components that are considered to be useful for a quality CSE.
McCallister et al. in 2016 reviewed 301 CSEs with finding of only 7/301 examinations having all items completed and only 57/301 having all cranial nerve components rated (4). This variability in components used most likely reflects clinical reasoning skills that draw on a wide variety of patient information collected and expert knowledge. The question remains: What is involved with a thorough CSE?
EMR Review
Physician notes: Note anything of relevance from the ED to code status
Find predisposing dysphagia risk factors, signs of possible chronic dysphagia, precipitating dysphagia risk factors, and risk factors for aspiration pneumonia.
Previous SLP notes can help you answer questions such as: Did this person have dysphagia previously? Has their baseline cognitive function and/or diet changed since last admission? What is this patient’s baseline?
Radiography, labs and medications are (in my opinion) often underutilized when trying to determine pathophysiology. Are these second nature to SLPs? Not necessarily. However, being informed on the basics can really step up our value to the medical team!
General observations
General neurological status can help us come up with hypotheses related to pathophysiology, dysphagia, and aspiration pna risk factors. Does the patient have any movement disorders? What is their cognitive-communication function level? Is this different from baseline? Any weakness?
Vitals: everything from respiratory rate (RR), blood pressure (BP), oxygen saturation (SpO2), heart rate (HR), and pain can contribute to dysphagia and safety when swallowing.
Modes of oxygen delivery and respiratory effort: This is highly important to consider. A patient with no dyspnea on 2 L/min will present very differently than one that is on 60% FiO2 high flow nasal cannula (HFNC). These two patients peak pharyngeal pressures could significantly vary to the point where we may not be able to temporarily offer safe PO intake (pending instrumental assessment if appropriate). We can visibly see if our patients are presenting with any abnormal respiratory patterns or are presenting with tachypnea.
Positioning and bracing may also alter our patient’s ability to tolerate PO or induce a temporary dysphagia from hard wiring.
Patient/caregiver interview
Does your patient complain of any dysphagia symptoms? Kelsey stressed how important asking open-ended questions with follow-up questions being yes/no to confirm any suspicions you may be having.
Sometimes our patients have displayed symptoms of dysphagia for a while with poor recognition due to dismissal or adapting. Caregivers may be aware of the deficits and can offer unique insight to our patient’s symptoms.
Cranial nerve (CN) exam
Kelsey went into great detail on how CNs V, VII, IX, X, and XII can lead us to hypotheses of pathophysiology and which instrumental evaluation may benefit that patient more.
For a more detailed course I would recommend ASHA’s Cranial Nerve Examination for the SLP by Kendra L. (Focht) Garand, PhD, CScD, CCC-SLP, BCS-S, CBIS, CCRE
Laryngeal function exam
Patient’s secretion management: Do they require suctioning? What does their cough and vocal quality sound like? Do you see excessive drooling? All of these things can tell us a lot about laryngeal functioning!
Vocal Quality: Kelsey discussed the utilization of the GRBAS and CAPE-V in acute care, outpatient, and long term care settings to provide the SLP valuable information about laryngeal function
Maximum Phonation Time (MPT): Best of three trials. Kelsey explained how this can help the SLP determine glottic sufficiency.
S/Z Ratio: Is there a laryngeal pathology? This ratio helps the SLP compare voiced and voiceless speech sounds.
Pitch Elevation: the perceptual correlate of fundamental frequency. Kelsey provided a beautiful reference from Malandraki et al., 2011 discussing how pitch elevation can provide information on anatomy, physiology, and neurophysiology with swallowing (5).
Cough: Kelsey went into great detail on how peak expiratory flow rate has been shown to demonstrate predictions in pulmonary complications, aspiration risk, airway invasion, and pneumonia in a variety of patient populations.
PO trials
Kelsey graciously maneuvered through the hot topic question of what and how much should we be using to assess the swallow at bedside.
She also discussed a variety of validated tools and standardized patient reported outcome measures to help the SLP assess quality of care, patient satisfaction, and differentiate between possibly normal and disordered swallowing.
Documentation (SOAP format)
Subjective: Discuss reasoning for referral, any patient/caregiver concerns for dysphagia, cognitive-communication fxn, pain, patient positioning, and respiratory efforts prior and during PO
Objective: EMR data (i.e. dysphagia predisposing and precipitating factors, signs of any possible chronic dysphagia), physical exam findings, any measurable data, patients consent/refusal
Assessment: document any clinical signs of suspected or probable dysphagia, etiology, need for instrumental, any risk factors for development of dysphagia-related pneumonia, and prognosis.
Plan: Are you recommending any instrumentals? Do they require any ancillary tests or referrals? How can the medical team participate in risk management? Can the patient tolerate a PO diet? Therapy recommendations or patient stated goals should also be documented.
After detailed instruction on a thorough CSE report we entered into a clinical writing workshop where we spent time with three case studies, producing a valuable report for each. Kelsey was extremely gracious with her feedback and gave us her written reports as well for examples. I personally found this invaluable to aid course participants in focusing on evidence based practices while increasing critical thinking skills for effective management.
Video Fluoroscopic Swallow Study
I’ve been spoiled when it comes to VFSS access since I’ve been a practicing SLP in acute care. Having the fluoro room down the hall and protocols set up allowing me free reign of ordering VFSS are things I sometimes take for granted. I can’t imagine having to battle with your facility or company just to get an instrumental for your ppatient. Although, this is very much a reality for many of our SLP colleagues.
Picture this. You’ve battled with your facility/company to get that patient an instrumental for weeks. The wait is finally over- the day of the instrumental is finally here! Your patient comes and tells you they only took a sip of thin liquid and the report is recommending honey thick liquids and puree.
Umm…what?
Does this sound like a SLP you know? Don’t be that SLP. I won’t lie- the fact that some SLPs still write reports like this INFURIATES me. What about compensatory strategies? Bolus size changes? Positioning changes? Anything and everything that happens in that fluoro room needs to be documented. Jerri Logemman herself reported on the importance of using compensatory strategies, sensory techniques, and multiple bolus trials in order to determine how to safely keep our patients eating and to determine swallow pathophysiology with diet modification as the last resort (6).
Palmer and colleagues proposed a protocol for the videofluoroscopic swallowing study which included (7):
Positioning of the patient
Bolus types presented
Strategies trialed
Detailed description of structural abnormalities
Summary of each observable functional swallow component
Diagnostic assessment
Recommendations
In my personal experience, I am MBSImP certified and love utilizing their report generator for consistency and as a time-saver with report writing (8).
Let’s dive into what should be included in our VFSS documentation.
Anatomical view
Are there any structural, post-surgical, or lines/tubes that are variations from the norm? Comment on them, as they may be contributing to your patient’s dysphagia symptoms.
PO trials
What type of barium products are you using in your study? Are they standardized? Are you using Varibar or EZ-Paste? This is important to note, as this can change the amount of residue we are seeing.
Oral and Pharyngeal phase + Esophageal screen
Kelsey beautifully covered exactly what we should be able to observe in each of these phases and what we should be documenting on.
Protocols like the MBSImP again allowqou to rank severity on each of these 17 components.
Compensatory strategies
Anything from posture changes, maneuvers, or bolus modifications should be documented on here. This should include how it impacted the swallow (positively, negatively, or even if there was no change in swallow fxn)
Penetration-Aspiration Scale (PAS) (9)
For those of you who are not aware of the PAS, this allows consistency between SLPs so we can understand the level of penetration/aspiration that occurred. This should be documented on each consistency.
Dysphagia Outcome and Severity Scale (DOSS) (10)
Kelsey did a fantastic job covering why she utilizes the DOSS, how it allows for consistency between clinicians, and how this helps her determine if this patient is OK on a modified diet or if we need to be considering enteral feeding.
Assessment
Without giving away too much knowledge from Kelsey’s course, she was able to find the perfect balance of being detailed and concise.
Details such as dysphagia diagnosis, etiology, commenting on swallow safety & efficiency, prognosis, diet modifications, and rehab candidacy were covered.
The assessment portion is crucial as it is often all the physician reads. It's imperative we communicate effectively to show our worth and advocate for our patients.
Plan
Essentially, what are you going to do to manage this patient’s dysphagia?
Did you see any need for diet modifications? How about for referrals or ancillary tests? What goals and therapeutic activities is your patient going to participate in? Do they need a follow-up examination?
We broke up into another writing workshop utilizing case studies to hone in our documentation skills for VFSS. Since this course was not focused on interpretation of the VFSS, these sections were not covered during the examination. If you are interested in learning more on VFSS interpretation, I would highly recommend completing the MBSImP and seeking mentorship from a SLP with experience.
Flexible Endoscopic Evaluation of Swallowing (FEES)
FEES seems to be gaining attention in the SLP world. Some SLPs are resistant to it while others fully embrace it. The MBS vs FEES debate: Which is the gold standard?
The answer is... BOTH!
FEES and MBS are both gold standards in diagnosing and developing a treatment plan for dysphagia, but provide different parts of the overall picture of what is going on with our patient.
FEES allows us to (11)
assess saliva/secretion management
visualize the laryngeal/pharyngeal structures
assess for vocal cord movement
Asses the pharyngeal phase of swallow
You can actually see aspiration and penetration
Can be done anywhere at any time, with no barium or radiation exposure.
How does a FEES report differ from a VFSS?
Subjective
This relatively is consistent with VFSS
Nasopharyngoscopic Findings
What does their anatomy look like? How is the velopharyngeal function?
Pharyngoscopic & Laryngoscopic Findings
Any anatomical abnormalities? How do the vocal folds move? Any secretions? Do you see the pharyngeal wall contract with non-swallow tasks?
PO trials
This differs from the MBS due to not having to limit the amount of trials you give your patient- there is no radiation exposure! This is your time to really determine swallow function and most appropriate diet
Oral and Pharyngeal phases
The esophageal phase cannot be viewed on FEES; however, take can be completed to screen for possible esophageal issues
Oral and pharyngeal components can still be assessed. However, all 17 found on the MBSImP cannot be seen on FEES. Kelsey discussed what we are able to accurately document on when completing FEES.
Compensatory strategies
Consistent with VFSS
PAS
Consistent with VFSS
Yale Pharyngeal Residue Severity Scale (12)
Helps the clinician identify severity for valleculae and pyriform sinus residue
FEES allows clear observation of how much residue is in the hypopharynx (unlike the VFSS)
Murray Secretion Scale (MSS) (13)
On a scale of 0-3
Aids in ranking amount of secretions and location of secretions.
DOSS
Consistent with VFSS
Assessment
Comsistent with VFSS
Plan
Consistent with VFSS
The third and final workshop commenced for FEES clinical report writing. As a clinician that is about to start conducting FEES on a regular basis, I was most excited for this portion of the course. Kelsey was able to make clinical documentation with FEES fluid and easily comprehensive for SLPs taking the course that were not familiar with FEES. This section of the course made me feel more at ease going into FEES training and also made me highly aware of what to look for in a thorough report.
Impressions:
Let me tell you guys... I’m blown away by Kelsey’s clinical documentation skills. My first patient after this course was an 89 year old woman admitted with a dx of pneumonia (believed to be aspiration-related) x3 a year since 2018 with an unknown etiology. Her EMR only listed recurrent aspiration pneumonia, fever, and COPD. When I got a hold of her she had been admitted for two days on a honey thick and pureed diet. She presented with tremors at rest, some muscle wasting, and multiple swallows of thin via cup, but otherwise no obvious deficits at bedside. The last time she saw a SLP was two years ago… She said, “they watched me eat and told me to eat thickened liquids and puree.” She was on honey thick liquids and puree for two years…. TWO YEARS! Her VFSS demonstrated severe pharyngoesophageal dysphagia with chronic and gross aspiration across all consistencies.. Kelsey’s documentation gave me the boost and confidence I needed to document clearly, communicate effectively, advocate for my patient’s wishes, and utilize evidence based practices to lead our medical team to readdress plan of care, goals, and code status. I’ve never seen this hospitalist react quite the way they did to my first note coming out of this class. I can’t wait to see the lives I’m going to change from learning how to vocalize the importance of SLP involvement in our patient’s clinical discourse.
Definitely keep an eye out for the next time this course is offered!
References:
Teichman, P. (2000, March 01). Documentation Tips for Reducing Malpractice Risk. Retrieved August 17, 2020, from https://www.aafp.org/fpm/2000/0300/p29.html
American Speech-Language-Hearing Association. (2010r). Code of ethics [Ethics]. Available from www.asha.org/policy
McAllister, S., Kruger, S., Doeltgen, S., & Tyler-Boltrek, E. (2016). Implications of variability in clinical bedside swallowing assessment practice by speech language pathologists. Dysphagia, 31 (5), 650-662.
Malandraki, G. A., Hind, J.A., Gangnon, R., Logemann, J.A., & Robbins, J. (2011). The utility of pitch elevation in the evaluation of oropharyngeal dysphagia: Preliminary findings. American Journal of Speech-Language Pathology, 20 (4), 262-268.
Logemann, J.A. (1997). Role of the modified barium swallow in management of patients with dysphagia. Otolaryngology-Head and Neck Surgery, 116(3), 335-338.
Palmer, J.B., Kuhlemeier, K.V., Tippett, D.C., & Lynch, C. (1993). A protocol for the video fluorographic swallowing study. Dysphagia, 8(3), 209-214.
Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., . . . Blair, J. (2008). MBS Measurement Tool for Swallow Impairment—MBSImp: Establishing a Standard. Dysphagia, 23(4), 392-405. doi:10.1007/s00455-008-9185-9
Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11(2), 93-98. doi:10.1007/bf00417897
O'neil, K. H., Purdy, M., Falk, J., & Gallo, L. (1999). The Dysphagia Outcome and Severity Scale. Dysphagia, 14(3), 139-145. doi:10.1007/pl00009595
Wallace, T. (2020, July 27). Why FEES? 7 Reasons to consider FEES. Retrieved August 18, 2020, from https://dysphagiaramblings.net/2019/08/05/why-fees-7-reasons-to-consider-fees/
Neubauer, P. D., Rademaker, A. W., & Leder, S. B. (2015). The Yale Pharyngeal Residue Severity Rating Scale: An Anatomically Defined and Image-Based Tool. Dysphagia, 30(5), 521-528. doi:10.1007/s00455-015-9631-4
Murray, J., Langmore, S.E., Ginsberg, S., Dostie, A., (1996). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11, 99-103
