SOAP

Question 1

Subjective

Answer 1

Age
Gender
LOC
Medical history
Pt complains of
MD concerned
Pt was referred for (MBS to assess swallow function and safety)

Question 2

Objective

Answer 2

Pt seen where? (in radiology)
Positioned (upright 90 degrees)
Viewed in (lateral and AP?)
Textures included

Question 3

Oral prep phase

Answer 3

Lingual skills
Labial skills
Dentition condition/mastication
Jaw excursion

Question 4

Labial skills

Answer 4

(No) diff taking material from utensil
(No) anterior food leakage
(No) pocketing

Question 5

Lingual skills

Answer 5

(Good) ROM/strength
(No) diff forming food into bolus
(No) pocketing in lateral/anterior sulci
(No) lingual stasis

Question 6

Dentition condition/mastication

Answer 6

No/some difficulty with mastication on any/x textures

Question 7

Jaw excursion

Answer 7

(Good) lip closure and jaw opening

(Good) mastication of material

Question 8

Oral transit phase

Answer 8

Increased due to: tongue pumping/thrusting… However eventually able to propel bolus into pharyngeal area

Question 9

Pharyngeal phase components (9)

Answer 9

VP closure
Swallow timeliness
Posterior tongue retraction
Posterior pharyngeal wall contraction
Laryngeal elevation/hyoid excursion
Epiglottic inversion from something other than laryngeal elevation
CP opening from something other than laryngeal elevation 
Aspiration/penetration
Unilateral pharyngeal weakness