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Dysphagia Assessment

By Ricardo Phillips,2014-10-17 11:30
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Dysphagia Assessment

Dysphagia Assessment

    Description Codes Findings Definitions ED Variable

     npoed Patient ID Did the patient receive any oral 1. Yes, patient received some food NPO = nothing by mouth If the patient received any intake including food, fluids, or fluids, or medications by mouth. food, fluids, or medications by mouth, 2. No (patient NPO during entire ER medications by mouth in the ED? stay.) answer “1.” If the patient was kept NPO the during the

    entire ED stay, answer "2."

    Do not consider the delivery of food, fluid,

    or medication via a nasogastric tube,

    orogastric tube, or percutaneous

    gastrostomy tube as intake by mouth (oral

    intake).

     eddyspo 1. Yes, patient screened for dysphagia Documentation in the record should indicate Was the patient screened for and documented patient able to that an assessment of the patient’s ability to oral intake including food, fluids, to swallow. swallow was completed by a health care or medications by mouth in the

    professional prior to oral intake of food, ED? 2. No, patient was not screened for fluids, or medications. The screening test dysphagia. should be a standardized method of 3. Yes, patient screened for dysphagia swallowing assessment accepted by the and documented unable to swallow.

     facility. The screening test does not 4. Yes, patient screened for dysphagia

    need to be a formal evaluation by a speech and screening result is not

     and language pathologist. documented.

     edystype What type of pre-po intake 1. Bedside functional test Bedside functional test: Documentation of observation of patient drinking a small amount of water without dysphagia screen was performed 2. Instrumental Evaluation cough of change in voice. in the ED? 3. Speech and Language These methods include, but are not limited Pathology (SLP) consult to: 4. Other type of screen • Bedside swallowing test 95. Not applicable • Simple water swallow test 99. None of the above or unable • Burke water swallow test to determine. • Simple standardized bedside swallowing assessment (SSA)

    If the bedside functional screen was not

     one of the screens listed above or used a

     fluid other than water, answer “4.”

    Instrument evaluation: 1

    Dysphagia Assessment

     • Barium swallow

     • Video fluoroscopy

     • Double contrast esophagoscopy

     • Radio nucleotide studies

     • Manometry

     • Scintigraphy

     • Fiberoptic endoscopic evaluation of

     swallowing (FEES)

     • Fiberoptic endocopic evaluation of

     swallowing with sensory

     test (FEEST)

     • Ultrasonography

     • Electromyography (EMG) Speech and Language Pathologist (SLP) consult = In order to select

    “3,” the SLP consult must document evaluation of the patient’s ability to swallow, eat, or drink.

    Exclude: Patient evaluation using NIH/NIHSS (National Institute of Health Stroke Scale) is NOT considered dysphagia screening; documentation of “gag reflex present” or “cranial nerves intact” without explicit assessment of swallowing is not considered dysphagia

     screening. INPATIENT

    admdcnpo Does the medical record document 1. Yes NPO = nothing by mouth If the patient was kept NPO the entire the patient was kept NPO for the 2. No hospitalization and was discharged / entire hospital stay? transferred/deceased NPO, answer "1." If the patient received any foods, fluids, or medications by mouth, answer “2.” Do not consider the delivery of food, fluid, or medication via a nasogastric tube, orogastric tube, or percutaneous

     gastrostomy tube as intake by mouth

     (oral intake).

    2

    Dysphagia Assessment

    scrdyspo Documentation in the record should indicate After admission, was the patient 1. Yes that an assessment of the patient’s ability screened/evaluated for dysphagia 2. No to swallow was completed by a health care before being given any oral intake 97. Reason documented by professional prior to oral intake of food, including food, fluids, or physician/APN/PA for not performing fluids, or medications. The screening test medications by mouth? screening/evaluation for dysphagia prior or evaluation should be a standardized to oral intake method of swallowing assessment accepted 99. Unable to determine by the facility. The screening test does not need to be a formal evaluation by a speech and language pathologist. Reasons for not

     Performing a dysphagia screen

    /evaluation before PO must be explicitly documented or clearly implied by the physician/APN/PA. If the reason is not

     mentioned in the context of dysphagia screening, do not make inferences. typoscrn What type of inpatient pre-po 1. Bedside functional test Bedside functional test: Documentation of observation of patient intake dysphagia screen and drinking a small amount of water without 2. Instrumental Evaluation evaluation was cough of change in voice. 3. Evaluation of swallowing by These methods include, but are not limited performed? Speech and Language Pathology to: (SLP) • Bedside swallowing test 4. Other type of screen • Simple water swallow test 95. Not applicable • Burke water swallow test

     • Simple standardized bedside

     swallowing assessment (SSA) If the bedside functional screen was not

     one of the screens listed above or used a

     fluid other than water, answer “4.” Instrument evaluation:

     • Barium swallow

     • Video fluoroscopy

     • Double contrast esophagoscopy

     • Radio nucleotide studies

     • Manometry

     • Scintigraphy

     • Fiberoptic endoscopic evaluation of

     swallowing (FEES)

     • Fiberoptic endocopic evaluation of

    3

    Dysphagia Assessment

     swallowing with sensory

     test (FEEST)

     • Ultrasonography

     • Electromyography (EMG) Speech and Language Pathologist (SLP) consult = In order to select

    “3,” the SLP consult must document evaluation of the patient’s ability to swallow, eat, or drink.

    Exclude: Patient evaluation using NIH/NIHSS (National Institute of Health Stroke Scale) is NOT considered dysphagia screening; documentation of “gag reflex present” or “cranial nerves intact” without explicit assessment of swallowing is not considered dysphagia

     screening. swalout If a bedside functional swallowing test Did the record document the result of 1. Okay for patient to eat and/or drink was performed, the result of the 2. Not okay for patient to eat and/or the pre-po intake dysphagia screening/ pre-po dysphagia screen may be taken drink evaluation? from a nursing or clinical note. If a drink radiological or instrument exam was 3. Result of dysphagia performed, the result may be taken from screen/evaluation

    the report of the exam, a clinician or not documented

    consult note. 95. Not applicable In order to answer “1,” there must be 99. Unable to determine documentation indicating

    that the patient is able to eat and/or drink.

    4

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