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Section Navigation Part 22 of 25 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. Subjective — ask 10. Objective — observe 11. Measure 12. 8. Interventions performed 13. 9. Patient and caregiver teaching 14. 10. Response and reassessment 15. 11. Physician or provider notification 16. 12. Red flags and emergency escalation 17. 13. Skilled-need justification 18. 14. Medical-necessity statement 19. 15. Homebound relevance 20. 16. Weak vs. strong documentation 21. 17. Common audit and denial risks 22. Smart phrases 23. Normal narrative bank — stable / at-baseline 24. Abnormal narrative bank — focused / at-risk 25. 19. Sources and clinical references Previous Next Smart phrases EMR dot-phrases; replace merge fields in braces. These supplement — not duplicate — the parent and overlay phrases. Chart only the elements actually assessed.
.SWAL_SCREEN
Swallow screen over [observed meal/trial]: cough/throat-clear [yes/no], wet voice [yes/no], pocketing [yes/no], multiple swallows [yes/no], meal duration [time]; [unchanged] from baseline.
.SWAL_IDDSI
Ordered IDDSI [level]; textures consumed [match/exceed]; thickened liquids [correct/incorrect] consistency; [correction/action].
.SWAL_POSITION
Positioning upright [90°] for/after meal [yes/no]; feeding technique [safe/corrected — pacing, bite/sip size]; oral residue [none/described].
.SWAL_ASPIRATION
Aspiration signs: post-meal dyspnea [yes/no], wet voice [yes/no], recurrent infection [yes/no], low-grade fever [yes/no]; assessment [none/aspiration concern]; [action].
.SWAL_SLP
SLP plan [level/maneuvers]; coordination [current/re-eval requested]; recommendations reinforced.
.SWAL_TEACH
Taught [safe-swallow strategies/positioning/IDDSI prep/caregiver feeding]; [patient/caregiver] return-demonstrated [result]; gaps [none/described].
.SWAL_NOTIFY
Provider/SLP notified at [time] of [finding]; orders received: [orders]; follow-through [completed/scheduled]; reassess [parameter] next visit.
Section Navigation Part 22 of 25 1. General Section 2. 1. Purpose and clinical relevance 3. 2. What the clinician must assess 4. Technique 5. Required data to chart 6. 4. Normal findings 7. 5. Abnormal findings 8. 6. Mode A — complete chartable narrative 9. Subjective — ask 10. Objective — observe 11. Measure 12. 8. Interventions performed 13. 9. Patient and caregiver teaching 14. 10. Response and reassessment 15. 11. Physician or provider notification 16. 12. Red flags and emergency escalation 17. 13. Skilled-need justification 18. 14. Medical-necessity statement 19. 15. Homebound relevance 20. 16. Weak vs. strong documentation 21. 17. Common audit and denial risks 22. Smart phrases 23. Normal narrative bank — stable / at-baseline 24. Abnormal narrative bank — focused / at-risk 25. 19. Sources and clinical references Previous Next