FEES Procedure Preparation and Documentation

This template covers the full FEES workflow from pre-procedure readiness through post-procedure documentation. It is designed to capture scope readiness, patient consent, pre-procedure vitals, the food and liquid consistencies trialed, patient tolerance, and the final findings. It works as a checklist so each step can be verified and documented in order.

It is intended for clinicians and support staff involved in swallowing evaluations, especially speech-language pathologists and other trained providers who perform or assist with FEES. The DRI should be the clinician responsible for the exam, while nursing or support staff can complete preparation items that are non-blocking. If your workflow separates setup from interpretation, this template can still be used as the shared record.

Use it every time a FEES procedure is performed. It is not a recurring administrative task; it is a per-patient, per-procedure checklist that should be completed once for each exam. If your site performs repeat FEES studies, clone the template for each encounter so the documentation stays tied to the specific visit.

Yes, it can be adapted for outpatient clinics, inpatient units, and bedside evaluations as long as the same core steps are relevant. The exact setup items may differ by location, but the checklist should still verify readiness, consent, vitals, trial consistencies, tolerance, and findings. If your setting has additional infection-control or transport steps, add them as local checklist items.

Common misses include documenting the exam without confirming consent, skipping pre-procedure vitals, failing to note which consistencies were trialed, and recording findings without a clear tolerance statement. Another frequent issue is using vague language like 'tolerated well' without specifying what was observed. This template pushes each item into an independently verifiable checklist item.

It supports documentation practices commonly expected in clinical records by making consent, patient status, procedure details, and findings explicit. It does not replace your facility policy, scope-of-practice rules, or local documentation standards. You should align the final checklist with your organization’s clinical governance, privacy, and retention requirements.

Yes, and you should. FEES documentation often needs local terminology for food and liquid consistencies, airway observations, residue patterns, and recommendations. Customize the checklist items so they match your protocol, but keep each item atomic and verifiable rather than combining multiple observations into one line.

Ad-hoc notes are easier to start but often miss critical steps or bury them in free text. A checklist format makes the exam easier to run consistently, easier to review, and easier to audit later. It also helps separate blocking steps, like consent and readiness, from non-blocking documentation details.