Clinical Writing for Dysphagia Diagnostics

 

Remember when I dedicated an entire blog post to the 17 physiologic components of the swallow? Basically I nerded out over the topic of evaluating and treating three phases of a swallow vs 17 whole components of a swallow as if they actually all worked synchronously with each other. Makes sense, right? Or the time that I wrote about getting solid FEES training because we really sorta do need you to know what you’re talking about when you go to write your report.

I’ve thought long and hard about this topic for YEARS but even more so recently as I’ve had to submit some reports for lawyers to review for various court cases they are working on. And you know what? (In my finest Kevin McAlister voice) “I wasn’t even scared anymore” to send in those reports! You know why? Because I understand the importance of clinical writing, and I’ve made an insane effort to get really, really super good at it.

Last year at our FEES Biz retreat, we spent several sessions talking about report writing from various experts in the field. From a business standpoint, I think it can absolutely be the downfall of a private company, whether it’s FEES, VFSS, or just private practice, if your writing stinks, it doesn’t help anybody.

When you get an VFSS or FEES report about a patient with dysphagia, you don’t really know how to plan appropriate therapy if all you see is “impaired pharyngeal phase.”

I know we’ve all seen reports in the past that have only documented three phases of the swallow, as if they are their own separate neighborhoods. What does that even mean? Where do treating SLPs go from reports like that? Even separate neighborhoods are all connected somehow! Like they all live in the same town right? Like they all need to know what each other is doing! (And of course it doesn’t help that our billing codes reflect the 3 phases of the swallow, but that’s another hill I’ll climb some other day)

I’ve seen things like, “Moderately impaired pharyngeal phase. Recommend intensive speech therapy.”

Excuse me while my neurons try to reboot and connect to each other in order to make something out of that…

Going even further down this rabbit hole, we all want respect. We walk the same floors as nurses, doctors, and several other allied health professionals. We need to talk like them too. We get frustrated when our physician colleagues diagnose a patient with dysphagia and put them on a puree diet with thickened liquids, but if that’s all they see our reports doing, then surely they might as well just make that recommendation for us right? Wrong.

We’re not trained monkeys, we’re speech-language pathologists that can diagnose and treat dysphagia. We want our colleagues to understand that we are a critical part of the medical team, and in order to do that our notes need to reflect that.

And last but not least, let’s not forget about our own! Our own SLP colleagues! How many times have we gotten very bare boned reports basically not even worth the paper they are written on. I know healthcare professionals are drilled in HIPAA and protecting patient information, but you can’t leave an SLP in the dark like that! What if we emphasized sharing and documenting relevant clinical information as much as we highlight HIPAA? In fact, if you look at the 7 Caldicott Principles, which are principles relating to patient confidentiality, you’ll see that Principle 7 is “the duty to share information can be as important as the duty to protect patient confidentiality.”

To further explain Principle 7:  “Health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by these principles. They should be supported by the policies of their employers, regulators and professional bodies” (Department of Health, pp. 21)

In order for a patient to truly receive evidence-based therapy, we need thorough clinical and instrumental assessments. And in order for assessments to be meaningful, we need high quality documentation. Imagine that.

That’s why I was SO excited when the amazing Kelsey Day wanted to join forces to put together an all-day clinical writing course.

For me if something isn’t a hell yes, then it’s a hell no, and this was a 100% a hell yes.

Like literally an entire course just on CLINICAL WRITING.

We had planned to do this course live in LA this past summer, but of course COVID. We had to swerve with a lot of our plans, but I truly believe it’s been a blessing since we’re able to reach soooo many more clinicians virtually with this course.

If I were to stand up in front of a crowd of medical SLPs and ask for those who feel absolutely confident in their clinical writing skills to speak up, do you know what I’d hear?

Crickets.

What about if your doctors and nurses actually read and not only read but actually LISTEN and RESPECT your notes?

Crickets again?

Dang.

Which makes me trust crickets even less if they’re going to speak up at a moment like that but I digress.

Clearly what I’m trying to say here is that very few of us, if any, can truly say that we can document the crap out of clinical swallowing evaluations, VFSSs, and FEES like champions based on grad school education alone! It’s not just new grads, either. There are a boatload of SLPs who complete swallow evaluations and aren’t aware of the importance of documenting things like neutrophil percentage, absolute neutrophil count, body mass index (BMI), arterial blood gas (ABG), or international normalized ratio (INR). Or maybe the flow of documenting cranial nerve exams is still super turbulent and all over the place, leaving you to think things like Shoot, did I document anything about the hypoglossal nerve? Does it matter?

Yes, yes it does.

Well, during the clinical writing course, we actually got to ask over 300 med SLPs about their clinical writing skills. Instead of crickets, we heard a bunch of people speak up about their lack of confidence or the feeling that their writing skills were just flat out terrible.

This eight-hour information-packed course allowed attendees to finally dig into the whole picture of dysphagia evaluations and documentation. Kelsey broke down the puzzle pieces SLPs need to collect when we evaluate a new patient for dysphagia and how to document it all. This includes things like the chart review, dysphagia risk factors vs aspiration pneumonia risk factors, labs, medications, patient/caregiver interview, cranial nerve exam, and everything about the swallow assessment itself while relating it back to the whole clinical picture. As the dysphagia detectives that we are, simply watching someone eat and writing about what we saw will miss the mark, and it certainly won’t gain the trust or respect of our patients and colleagues.

Skills were discussed in three phases (no, not oral, pharyngeal, and esophageal- although this was discussed):

Report writing for:

  1. Clinical Swallow Evaluations
  2. VFSS
  3. FEES

For Clinical Swallow Evaluations, Kelsey reviewed:
-What to look for in physician notes
-Documenting predisposing dysphagia risk factors and signs possible chronic dysphagia
-Precipitating dysphagia risk factors (ie acute medical conditions that could lead to dysphagia)
-Risk factors for aspiration pneumonia
-Radiography
-Labs
-Medications
-General observations
-Patient/caregiver interview
-Cranial nerve exam
-Laryngeal function exam
-PO trials

For VFSS and FEES, we reviewed:
-Projections and anatomy
-PO trials
-Swallow phases and the 17 physiologic components of the swallow
-Outcome measurement and rating scales

And how to put it alllll together in documentation.

Once the puzzle pieces were splayed out on our computer monitors, we practiced putting everything together in a writing workshop for each category, which included three case studies each (i.e. nine case studies total)

Three clinical writing topics.

Three writing workshops.

Three case studies each.

All dedicated to improving clinical documentation skills on so much more than just three phases of the swallow.

Over 300 brains were full and the confidence levels were boosted by the end of this course. What I love about that is that it means thousands of patients will now benefit from improved therapy because of solid, detailed, relevant clinical documentation skills.

If you would like to buffer your clinical writing game, or learn more about what exactly you should be including in your notes, we will be hosting this course again Saturday, November 7.

Not only do you get to attend an all day LIVE and INTERACTIVE course for 0.8 ASHA CEUs, but we also give you 150, yes that’s 150 sample reports. 100 clinical swallow reports, and 25 each of VFSS and FEES sample reports. Not sure how to document a specific case or condition? There’s most definitely a sample for that. And for all of our extremely organized type A friends? We have it all in searchable database for you to pull up on the fly. These reports alone are so incredibly helpful.

We hope you’ll join us for the next course! You can register here.

References:

Department of Health. (2013, March 21).  The Information Governance Review: To Share or Not to Share. National Information Governance Board. Retrieved at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/192572/2900774_InfoGovernance_accv2.pdf


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