Clinical Swallow Evaluation (Bedside Dysphagia Assessment)

Bedside clinical swallow evaluation template for speech-language pathologists to document oral motor findings, trial swallows by consistency, aspiration signs, and recommendations for instrumental assessment.

Assessment Context and Readiness

• Patient identity and evaluation reason documented
  Record the patient identifier, referral reason, and clinical indication for the bedside swallow evaluation.
• Alertness and participation adequate for bedside assessment
  Patient is sufficiently alert, cooperative, and able to follow commands for valid swallow trials.
• Positioning at least 90 degrees upright
  Patient positioned upright and stable for oral intake trials.
• Current diet status and NPO status documented
  Document current diet order or NPO status before trials.

Oral Motor and Structural Exam

• Labial seal and symmetry observed
  Assess lip closure, symmetry, and ability to maintain anterior oral containment.
• Lingual range of motion and coordination observed
  Assess tongue protrusion, lateralization, elevation, and coordination.
• Jaw opening, strength, and control observed
  Assess mandibular control and ability to open/close for bolus acceptance and mastication.
• Oral cavity, dentition, and secretion management documented
  Document dentition, mucosal condition, oral hygiene, and ability to manage secretions at baseline.

Swallow Trials by Consistency

• Thin liquid trial completed
  Document whether thin liquid trials were administered and tolerated.
• Thin liquid findings documented
  Record bolus size, number of trials, oral containment, swallow timing, and any coughing, throat clearing, wet vocal quality, or multiple swallows.
• Nectar/mildly thick liquid trial completed
  Document whether nectar/mildly thick liquid trials were administered and tolerated.
• Puree trial completed
  Document whether puree trials were administered and tolerated.
• Soft solid or regular solid trial completed
  Document whether solid food trials were administered and tolerated, when clinically appropriate.

Aspiration Signs and Airway Protection

• Coughing or throat clearing during or after swallow
  Observe for overt signs of airway invasion during or after trials.
• Wet or gurgly vocal quality after swallow
  Assess for change in vocal quality suggestive of residue or aspiration.
• Respiratory change or increased work of breathing observed
  Document tachypnea, desaturation, wheeze, distress, or other respiratory compromise associated with trials.
• Multiple swallows, oral residue, or suspected pharyngeal residue documented
  Describe residue patterns, need for repeat swallows, and any compensatory responses observed.

Clinical Impression and Recommendations

• Clinical impression of swallow safety documented
  Summarize bedside findings and overall clinical impression.
• Diet and liquid recommendation documented
  Document recommended diet level, liquid consistency, and any supervision or feeding assistance needs.
• Compensatory strategies or precautions documented
  Document strategies such as small sips, slow rate, alternate solids/liquids, upright posture, or oral care recommendations.
• Instrumental assessment recommended when indicated
  Indicate whether VFSS/MBSS, FEES, or no instrumental study is recommended based on bedside findings.