Click-to-copy diet levels & modifications documentation for SLPs in skilled nursing. Free, no login.
Patient downgraded to pureed textures based on request/comm of CNAs as they report that patient presents with adequate arousal at start of meal but quickly fatigues and decr in ability to safely manage mechanical soft textures. SLP assessed patient and observed the s/s of dysphagia that arise as he fatigues and concurred that safest diet is puree/thins via open cup or spoon. SLP also reminded CNAs not to try to feed patient if he is not responding as aspiration risk is greater if he cannot effectively manage food in oral cavity.
Patient completed oral strengthening ex in 3 sets of 10 reps. No overt s/s of dysphagia present. Patient observed with adequate ability to manage mech soft consistency on this date. Patient intook all liquids on tray. Patient stated she avoids the breakfast sausage because it upsets her stomach. 25-50% of tray was consumed on this date.
Patient downgraded to --- textures 2/2 --- observed during meal observation. Recommendation comm to nursing and dietary; MD made aware.
Patient upgraded to --- with --- liquids following --- consecutive meals without overt s/s of aspiration. SLP will continue to monitor tolerance.
Meal observation completed x --- min. Patient consumed ~---% of tray with --- overt s/s of aspiration. Rate of intake --- ; SLP provided --- cueing for pacing.
Patient tolerating --- with --- liquids, success in ---% of opps. No overt s/s of dysphagia present at this level.
Trial of --- texture completed x --- boluses. Patient demonstrated --- oral manipulation and --- pharyngeal clearance. SLP recommends --- at this time.
IDDSI level --- recommended based on this date's presentation. Rationale: --- . Recommendation comm to nursing, dietary, and MD.
Patient requesting --- despite current order for --- . SLP educated patient on the rationale for the current level and the risks of ---; patient verbalized --- understanding.
Liquids trialed at --- consistency x --- boluses. Patient demonstrated --- with thin and --- with ---, supporting continued recommendation of --- .
Patient requires --- level of assist for self-feeding and --- cueing for bite size. Recommendations for tray setup comm to nursing.
Alternating solids and liquids trained x --- opps to clear oral and pharyngeal residue. Patient carried the strategy over in ---/--- opps without cueing.
Patient's intake has been ---% across the past --- meals per nursing report. Findings comm to dietary 2/2 --- risk. SLP will reassess texture tolerance on ---.
Medication administration trialed in --- . Patient demonstrated --- ; recommendation of --- comm to nursing.
Skilled SLP required to determine the least restrictive diet the patient can safely tolerate, weighing aspiration risk against nutrition, hydration, and quality of life. This judgment cannot be delegated.
Patient/family expressed preference for --- despite documented aspiration risk. SLP provided education on risks and alternatives; --- comm to the interdisciplinary team for discussion of patient-directed feeding.