Use when the patient is swallowing safely on the ordered texture with correct precautions. Fill the bracketed blanks with the visit’s actual findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled swallow and aspiration-safety assessment completed. Tolerates the ordered [IDDSI level] across [an observed meal / a trial] without coughing, throat-clearing, a wet voice, or pocketing; voice clear before and after swallowing. Food and liquid textures match the order; thickened liquids [prepared correctly]. Positioned upright at ninety degrees for and after the meal, with safe feeding technique. Oral control adequate without significant residue. [No] aspiration signs — no post-meal dyspnea, wet voice, or respiratory-infection pattern. The observed swallow and the verified texture adherence against baseline confirm the ordered precautions remain protective and the plan is appropriate to continue; safe-swallow strategies, positioning, and IDDSI preparation were reinforced with the patient/caregiver, who [teach-back result], and the findings coordinated with SLP (cross-reference Nutrition, Respiratory).
Short form
Skilled swallow assessment: tolerates ordered [IDDSI level], no cough/wet voice/pocketing; textures match order; upright 90°, safe feeding technique; no aspiration signs. Precautions protective, plan continued. Safe-swallow/positioning teaching reinforced, teach-back correct; SLP coordinated.
