Report Writing

Question 1

What is the goal of the SOAP note?

Answer 1

To “Paint the picture” for the MD and insurance company of what the patient’s swallow problem is.

Question 2

What should go in the Subjective portion of your SOAP note?

Answer 2

includes age

level of care

medical history

patient complaint (In quotes)

Medical Hx.

clinical/bedside swallow eval findings

MD concerns

what they’re being referred for

Example: Pt. is a 76 year old male living at the independent level of care. Med hx=Parkinson’s Disease, COPD, GERD. Pt. c/o food “sticking in throat”. MD concerned w/ aspiration/dysphagia. He’s being referred for an MBS to assess swallow function and safety.

Question 3

What should go in the Objective portion of your SOAP note?

Answer 3

Includes what was done.

Include views (lateral? A-P?) and textures tried

Example: Modified barium swallow study completed in conjunction with radiology department. Pt. seated in upright position (90 degrees) & viewed in the lateral and A-P positions. Texture trials included: thin liquid, nectar thick liquid, pureed, wet soft, dry soft, meat, dry-crumbly, and tablet.

Question 4

What should go in the Assessment portion of your SOAP note?

Answer 4

Include phases of swallowing here. Include the deficits. Make sure you discuss ‘causes & effects’ and strategies/positioning that worked.

This is meat of it all.

See handout for examples.

Question 5

What should go in the Plan portion of your SOAP note?

Answer 5

Include what your plan is. What are your recommendations?

make sure you include:

• diet recommendations (both solid & liquids)
• Swallow therapy recommendations (frequency & duration)
• positions
• strategies
• exercises
• stimulation techniques
• other specialty recommendations (GI, UGI, voice eval, etc.)
• Goals

Question 6

EXample Plan

Answer 6

1. Diet=pureed w/ nectar liquids
2. swallow tx. 3x/wk for 2 wks
3. Strategies
   -small bites/sips
   chin tuck w/ liquids
   -hard swallow
   repeat/extra swallows
   alternate solids w/ liquids
   periodic throat clears
4. Recommend: GI consult
5. Goals: Pt. will verbalize & Demonstrate his swallow safety strategies w/out visual cues at 80% accuracy.
   - patient will show no pharyngeal red flags while performing his strategies.
   - patient will report no episodes of ‘choking’ while outside the clinic while performing his strategies.
   - patient’s diet will safely be upgraded to mechanical soft w/ thin liquids by the end of therapy.
   - recording of MBS will be reviewed w/ patient and spouse for education.

Question 7

What is the difference between swallowing efficiency vs. swallowing safety?

Answer 7

swallowing efficiency is not swallowing safety–it’s inefficient if they are basically burning more calories with their strategies/intake of food than the food actually has.

Can be affected by cognitive/behaviors as well.