Assess swallowing and aspiration risk in the context of the skilled reason and document the judgment:
Signs of dysphagia at meals: coughing or choking, a wet or gurgly voice after swallowing, pocketing, prolonged meal time, drooling, and — importantly — signs suggesting silent aspiration (a change in respiratory status or low-grade fevers without overt coughing).
The diet texture and liquid consistency in use (IDDSI level where adopted), the aspiration precautions (upright positioning, small bites, chin tuck, thickened liquids), and adherence.
The response to the swallow plan and any diet-texture progression, and taste changes affecting intake (post-radiation, medication, neurologic).
MDS-supportive data
Swallowing-disorder signs are coded in MDS Section K0100 and nutritional approaches in K0510, with cognition in Section C and the diagnosis in Section I. The record must document the swallowing assessment, the aspiration precautions, and the diet so the MDS is supported.
