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Patient Status (SLP)
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Last Seen
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Patient last seen by
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Patient Last Seen On Date
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Clinician Notification
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Support Notified
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Response
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General Information
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Precautions / limitations: Vision
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Precautions / limitations: hearing
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Barriers to Learning
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Pain Rating at Rest
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Pain Rating during Evaluation
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Baseline Assessment
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Respiratory Status
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History of Intubation
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Intubation Removal Date
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Intubation Start Date
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Trach Date
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Trach Type / Size
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Behavior / Cognition
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Patient Positionoing
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Baseline Vocal Quality
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Spontaneous Cough
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Spontaneous Swallow
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Motor Speech
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Labial Range of Motion
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Labial Description
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Labial Symmetry
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Labial Strength
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Labial Sensation
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Facial Range of Motion
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Facial Description
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Facial Strength
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Facial Symmetry
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Facial Sensation
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Velum
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Velum Description
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Mandible
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Mandible Description
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Vocal Intensity
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Voice Description
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Vocal Quality
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Intelligibility
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Intelligibility Description
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Gag
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Gag Description
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Consistencies Assessed
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Ice Chips
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Presentation
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Oral
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Pharyngeal
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Thin
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Presentation
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Oral
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Pharyngeal
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Mildly Thick (Nectar)
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Presentation
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Oral
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Pharyngeal
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Puree
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Presentation
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Oral
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Pharyngeal
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Soft & Bite-sized
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Presentation
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Oral
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Pharyngeal
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Regular
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Presentation
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Oral
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Pharyngeal
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Recommendations
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Risk for Aspiration
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NPO
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Medication administration
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Liquids
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Solid Diet Level
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Swallowing Strategies
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Instrumental Evaluation Recommended
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Therapy Summary
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Therapy Summary
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Clinical Impressions
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Rehab Potential
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Patient / Family Goals Statement
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Demonstrates Need for Referral to Another Service
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Additional Information
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Patient is a candidate for skilled SLP services
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Patient is not a candidate for skilled SLP services due to
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Anticipated Discharge Disposition
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