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Run: Dysphagia Diet Downgrade Notification

This dysphagia diet downgrade notification template documents a speech-language pathology recommendation to change texture or thickened liquid levels and sha...

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Notification Details

Notification Date (required)

Recommended By (required)

Enter the name and credentials of the speech-language pathologist or authorized clinician.

Service Location (required)

Reason for Diet Downgrade (required)

Clinical Summary (required)

Briefly summarize the swallowing change and the observed or documented findings supporting the recommendation.

Current Diet Order

Current Solid Texture (required)

Current Liquid Level (required)

Current Meal Supervision / Assistance

Recommended Diet Change

Type of Change (required)

Recommended Solid Texture

Recommended Liquid Level

Effective Date (required)

Enter the date the recommendation should take effect per facility workflow.

Implementation Instructions (required)

Include any mealtime strategies, positioning, pacing, supervision, or medication administration considerations needed for safe implementation.

Communication and Follow-Up

Notified Roles (required)

Was the patient or care partner notified? (required)

Follow-Up Needed

Select if additional SLP reassessment, instrumental study, or provider review is needed.

Yes No N/A

Follow-Up Details

Describe the next step, target date, or monitoring plan.

Acknowledgment

Acknowledged By (required)

Name and role of the person acknowledging receipt of the recommendation.

Acknowledgment Date (required)

Additional Comments

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