Dysphagia Diet Downgrade Notification

A clinical notification form for documenting a speech-language pathology recommendation to downgrade diet texture or thickened liquid level and communicate the change to care teams.

Notification Details

• Notification Date
• Recommended By
  Enter the name and credentials of the speech-language pathologist or authorized clinician.
• Service Location
• Reason for Diet Downgrade
• Clinical Summary
  Briefly summarize the swallowing change and the observed or documented findings supporting the recommendation.

Current Diet Order

• Current Solid Texture
• Current Liquid Level
• Current Meal Supervision / Assistance

Recommended Diet Change

• Type of Change
• Recommended Solid Texture
• Recommended Liquid Level
• Effective Date
  Enter the date the recommendation should take effect per facility workflow.
• Implementation Instructions
  Include any mealtime strategies, positioning, pacing, supervision, or medication administration considerations needed for safe implementation.

Communication and Follow-Up

• Notified Roles
• Was the patient or care partner notified?
• Follow-Up Needed
  Select if additional SLP reassessment, instrumental study, or provider review is needed.
• Follow-Up Details
  Describe the next step, target date, or monitoring plan.

Acknowledgment

• Acknowledged By
  Name and role of the person acknowledging receipt of the recommendation.
• Acknowledgment Date
• Additional Comments