Dysphagia Diet Downgrade Notification

A clinical notification form for documenting a speech-language pathology recommendation to downgrade diet texture or thickened liquid level and coordinate communication with nursing, dietary, and the physician.

Notification Details

• Patient Identifier
  Enter the facility patient ID or medical record number. Do not enter SSN.
• Patient Name
  Enter the patient's name for clinical communication and audit trail.
• Notification Date
• Notification Time
• Initiated By
  Name and role of the person completing the form, such as SLP or SLP assistant.
• Reason for Notification
  Briefly describe the swallowing safety concern or reassessment finding supporting the recommendation.

Current Diet Order

• Current Diet Texture
• Current Thickened Liquid Level
• Current Diet Notes
  Add any relevant details about current restrictions, supervision, or compensatory strategies.

Recommended Diet Change

• Recommendation Type
• Recommended Diet Texture
• Recommended Thickened Liquid Level
• Recommended Strategies
  Select any compensatory strategies or precautions to accompany the downgrade.
• Clinical Rationale
  Summarize the clinical findings supporting the recommendation, such as coughing, wet vocal quality, aspiration risk, or instrumental assessment results.

Communication and Follow-Up

• Nursing Notified
• Dietary Services Notified
• Physician Notified
• Notification Method
• Follow-Up Required
• Follow-Up Details
  Describe any required re-evaluation, monitoring, or pending orders.

Acknowledgment

• Physician Acknowledgment
  Use if your facility workflow requires physician acknowledgment or co-signature.
• Implementation Notes
  Record any barriers, exceptions, or special instructions for implementation.
• What happens after I submit?
  This notification will be routed to the appropriate care team members for review and implementation according to facility policy.