Download Speech Language Pathology Note

Speech Language Pathology Note
Patient Name: _______________________________________________Date of Service: _________________________
Patient DOB: __________________________Medical Record Number: ___________________________
SUBJECTIVE:
Diagnosis: __ALS __bulbar __spinal __PLS Family/Friend Present: __________________________
Orientation/cognition: _ WFL _Moderate _N/A
Medical History: _______________________________
Activity: _WFL _Moderate _N/A
_____________________________________________
Consumes: H2O:_________ Caffeine/carbonated: _____
Medications:__________________________________
Diet: Solids: _Regular _Mechanical Soft _Minced/diced _Puree Liquids: _Thin _Nectar-thick _Honey-thick _NPO _PEG tube
Weight change since last visit _________________________ Patient Complaint/ Report: ______________________
__________________________________________________________________________________________________
OBJECTIVE:
____ Evaluation (Assessment)
____ Education & Treatment
___Oral-Motor Assessment [Present= “+”, Not Present= “–”; WFL= “0”, Mild= “1”, Moderate= “2”, Severe= “3”, Not Functional= “4”]
Symmetry
Strength
Range of Motion
Pace Mobility
IOPI
Fasciculation
Facial
Mandibular (jaw)
Labial (lips)
(30-60)
Lingual (tongue)
(40-80)
Velum
Saliva management: 0 1 2 3 4
Productivity of Cough: 0 1 2 3 4 Dentition:__________________________
COMMENTS: _______________________________________________________________________________________
__________________________________________________________________________________________________
Speech Communication and Alternative & Augmentative Communication (AAC): ____ speech change present
____AAC Strategies (communication boards, white boards, etc) ____AAC Devices (low-tech, high-tech, eye-gaze)
____ iPAD Text-to-Speech Applications/accessories ____Voice Amplification __ Voice Conservation
Observation of posture and upper limb mobility/function (prognosis for AAC):___________________________________
Notes: ____________________________________________________________________________________________
Perceptual Voice and Speech Assessment GRBAS: Grade: ___Roughness:___ Breathiness:___ Asthenia:___ Strain:___
__Dyspnea __Low/ High Pitch __Reduced / Increased Loudness __Hyper/Hypo– nasal
__Slurred Speech
__Slow Speech Rate __Reduced stress __Short phrases __Imprecise Consonants __Distorted Vowels
Intelligibility (%): ______
[WFL ( >85); Mild ( 84-75); Moderate (74-60); Severe (59-40); Not Functional (<39)]
Dysarthria:
WFL
Mild
Moderate
Severe
Not Functional
Diadochokinetic rate (puh)_____ (tuh)_____ (kuh)_____ (puhtuhkuh)________________________
Comments:_________________________________________________________________________________________
__________________________________________________________________________________________________
3 Oz water swallow: ____ WNL _____ Abnormal
___Clinical Swallow Evaluation (c=cup, s=straw)
Consistencies Presented: Thin___ Nectar ___ Honey___ Puree:___ Semisolid: ___ Cracker: ___
Labial control
Bolus control
Mastication
Laryngeal Elevation
Swallow Initiation
S/S of Impairment
Oral Phase
Pharyngeal
Phase
[WFL= “0”, Mild= “1”, Moderate= “2”, Severe= “3”, Not Functional= “4”]
Oropharyngeal Control
Comments: ________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
___Education & Treatment completed today
Dysphagia:
WFL Mild
Moderate
Severe
Not Functional
Swallowing Safety: __Slow Pace/ Small Intake of Solids and Liquids
__ Alternate bites and sips/ with cold food
__ Chin tuck
__Hard/effortful / multiple swallows __ Head turn ( left / right )
Diet Recommendations: ___ cleared for oral intake __ cannot recommend safe prandial nutrition
Liquids: __ thin __Nectar-thick __Honey-thick
Solids: __ general __soft/easy mastication __ diced __puree
Medications __ no changes __cut __crush __in apple sauce/ yogurt/ grape jelly/ pudding
___Weight maintenance __PEG Tube __increase hydration __oral hygiene __acid reflux management
Notes: ____________________________________________________________________________________________
Diagnostic Coding
Swallow/Dysphagia
Eval: G8996 __ Goal: G8997 __ Discharge: G8998__
Motor Speech
Eval: G8999 __ Goal: G9186 __ Discharge: G9158 __
Modifiers:
CH 0%, CI 1-19%, CJ 20-39%, CK 40-59%, CL 60-79%, CM 80-99%, CN 100%
Impressions/Assessment:
Primary Diagnosis:
Secondary Diagnosis:
PLAN / RECOMMENDATIONS:
1.
2.
3.
4.
________________________________________
_________________________________________
Debra Suiter, PhD CCC-SLP
Physician
Speech Language Pathologist