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Run: Dysphagia Diet Downgrade Notification

Use this Dysphagia Diet Downgrade Notification template to document an SLP recommendation to change texture or thickened liquids and route it to nursing, die...

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Notification Details

Patient Identifier (required)

Enter the facility patient ID or medical record number. Do not enter SSN.

Patient Name (required)

Enter the patient's name for clinical communication and audit trail.

Notification Date (required)

Notification Time (required)

Initiated By (required)

Name and role of the person completing the form, such as SLP or SLP assistant.

Reason for Notification (required)

Briefly describe the swallowing safety concern or reassessment finding supporting the recommendation.

Current Diet Order

Current Diet Texture (required)

Current Thickened Liquid Level (required)

Current Diet Notes

Add any relevant details about current restrictions, supervision, or compensatory strategies.

Recommended Diet Change

Recommendation Type (required)

Recommended Diet Texture (required)

Recommended Thickened Liquid Level (required)

Recommended Strategies

Select any compensatory strategies or precautions to accompany the downgrade.

Clinical Rationale (required)

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

Yes No N/A

Dietary Services Notified

Yes No N/A

Physician Notified

Yes No N/A

Notification Method (required)

Follow-Up Required (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.

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