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 indication documented
  Confirm the evaluation note identifies the patient and states the clinical reason for the swallow assessment.
• Alertness, cooperation, and ability to participate documented
  Document whether the patient was sufficiently alert and cooperative for valid bedside trials.
• Positioning optimized for swallow trials
  Patient should be positioned upright as safely tolerated before oral trials.
• Oral intake restrictions or NPO status reviewed
  Document whether current diet order, NPO status, aspiration precautions, or relevant restrictions were reviewed before testing.

Oral Motor and Structural Exam

• Labial seal and symmetry assessed
  Assess lip closure, symmetry, and ability to maintain anterior bolus containment.
• Lingual range of motion and strength assessed
  Document tongue mobility, coordination, and strength relevant to bolus manipulation.
• Jaw, palate, dentition, and oral cavity integrity assessed
  Document structural findings that may affect mastication, bolus control, or residue.
• Volitional cough and throat clear assessed
  Document airway-protective responses relevant to aspiration risk.
• Voice quality at baseline documented
  Record baseline vocal quality before any PO trials.

Swallow Trials by Consistency

• Thin liquid trial completed and tolerated
  Document response to thin liquid trials, including cough, throat clear, wet voice, or respiratory change.
• Mildly thick / nectar-thick liquid trial completed and tolerated
  Document response to mildly thick liquid trials if clinically appropriate.
• Puree trial completed and tolerated
  Document response to puree trials, including oral residue, delayed swallow, cough, or wet vocal quality.
• Soft solid / regular solid trial completed and tolerated
  Document mastication, bolus formation, oral residue, and airway signs with solids.
• Multiple swallows, delayed swallow initiation, or oral residue observed
  Select all observed swallow inefficiencies across trial consistencies.

Aspiration Signs and Airway Protection

• Coughing, throat clearing, or choking observed during or after trials
  Document overt airway compromise during or immediately after PO trials.
• Wet or gurgly vocal quality after swallow observed
  Wet vocal quality after swallowing may indicate laryngeal penetration or aspiration.
• Respiratory change or increased work of breathing observed
  Document oxygen desaturation, tachypnea, dyspnea, or visible respiratory distress associated with trials.
• Signs of silent aspiration suspected
  Use clinical judgment to note concern for aspiration without overt cough or throat clear.

Clinical Impression and Recommendations

• Need for instrumental swallow study determined
  Document whether VFSS/MBSS or FEES is recommended based on bedside findings.
• Diet and liquid recommendation documented
  Record the recommended diet level, liquid consistency, supervision needs, and compensatory strategies.
• Patient education and follow-up plan documented
  Document education provided, aspiration precautions, and follow-up recommendations.
• Clinical swallow evaluation completed by SLP
  Inspector signature or attestation that the bedside swallow evaluation was completed and documented.