Click-to-copy aspiration precautions documentation for SLPs in skilled nursing. Free, no login.
Patient was woken up by SLP to participate in morning meal. Patient consumed ~50% of tray provided, sans overt s/s of aspiration. Patient completed 5 sets of 10 reps of lingual strengthening ex to improve lingual strength and coordination.
Patient educated on aspiration precautions including upright positioning at --- degrees, small bites/sips, --- , and remaining upright x --- min post meal. Patient verbalized ---/--- precautions on recall.
Nursing educated on the patient's aspiration precautions and the specific cueing required at meals. Nursing returned demonstration with --- accuracy.
Patient was woken by SLP to participate in --- meal. Patient consumed ~---% of tray, sans overt s/s of aspiration. Arousal --- throughout.
Patient observed at --- meal for compliance with precautions. Patient independently maintained --- of --- precautions and required --- cueing for ---.
Oral care completed/trained prior to PO intake to reduce bacterial load and pneumonia risk. Nursing educated on the --- schedule.
Patient positioned at --- degrees for PO intake. Patient --- maintain position independently and required --- for repositioning during the meal.
Patient demonstrated --- s/s of aspiration during PO trials including --- . Trials modified to --- and nursing notified.
Patient's arousal fluctuated during the meal; SLP --- and provided --- cueing to sustain alertness for safe intake. Recommendation of --- comm to nursing.
Signage for aspiration precautions placed at bedside and reviewed with patient, nursing, and family. All parties verbalized --- understanding.
Patient self-feeding at a rate of --- . SLP provided --- cueing for pacing and bite size to reduce risk of airway compromise.
Patient c/o --- during/after PO intake, consistent with --- . Findings comm to nursing and MD; SLP recommends --- .
Silent aspiration remains a risk given --- ; overt s/s are not a reliable indicator for this patient. Skilled SLP required to interpret subtle signs and adjust the plan accordingly.
Patient's precautions reviewed for continued appropriateness. Precautions remain indicated 2/2 --- and will continue per POC.