Date:
Patient:
MRN:
Clinician: (Speech-Language Pathologist, Physician, etc.)
Reason for Visit:
Follow-up for esophageal dysphagia
Evaluation of swallowing function
Adjustment of diet or feeding strategies
Management of aspiration risk
History of Present Illness:
Briefly describe the patient’s dysphagia symptoms:
Onset (gradual, sudden)
Type of difficulty (solids, liquids, both)
Associated symptoms (coughing, choking, chest pain, regurgitation)
Impact on nutrition and hydration
Past Medical History:
Include any relevant past medical conditions that may contribute to dysphagia, such as:
Gastroesophageal Reflux Disease (GERD)
Stroke
Head and neck cancer
Neurological conditions
Medications:
List any medications that may affect swallowing, such as sedatives or muscle relaxants.
Social History:
Diet history (texture modifications, oral intake limitations)
Tobacco and alcohol use
Swallowing Evaluation:
Briefly describe the type of swallowing evaluation performed (clinical swallowing exam, FEES [Flexible Endoscopic Evaluation of Swallowing], etc.)
Summarize the findings of the evaluation:
Oral motor function
Pharyngeal strength and coordination
Esophageal phase (presence of stricture, discoordination)
Presence of aspiration
Assessment:
Summarize the cause (if identified) or suspected cause of esophageal dysphagia.
Describe the severity of dysphagia (mild, moderate, severe).
Assess the patient’s risk for aspiration pneumonia.
Plan:
Outline the treatment plan for dysphagia:
Diet modifications (texture recommendations, thickened liquids)
Swallowing exercises (if appropriate)
Feeding strategies (oral intake, thickened liquids, enteral feeding)
Referral for additional evaluation or treatment (surgery, GI consult, etc.)
Monitoring plan for response to treatment and nutritional status
Prognosis:
Briefly discuss the potential for improvement in swallowing function with treatment.
Education:
Document any education provided to the patient and/or caregiver regarding:
Safe swallowing strategies
Diet recommendations
Signs and symptoms of aspiration
Notes:
Include any additional relevant information not covered above.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.