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Clinical Writing for Dysphagia Diagnostics

Clinical Writing for Dysphagia Diagnostics

Remember when I dedicated an entire blog post to the 17 physiologic components of the swallow? Basically I nerded out over the topic of evaluating and treating three phases of a swallow vs 17 whole components of a swallow as if they actually all worked synchronously with each other. Makes sense, right? Or the time that I wrote about getting solid FEES training because we really sorta do need you to know what you’re talking about when you go to write your report.

I’ve thought long and hard about this topic for YEARS but even more so recently as I’ve had to submit some reports for lawyers to review for various court cases they are working on. And you know what? (In my finest Kevin McAlister voice) “I wasn’t even scared anymore” to send in those reports! You know why? Because I understand the importance of clinical writing, and I’ve made an insane effort to get really, really super good at it.

Last year at our FEES Biz retreat, we spent several sessions talking about report writing from various experts in the field. From a business standpoint, I think it can absolutely be the downfall of a private company, whether it’s FEES, VFSS, or just private practice, if your writing stinks, it doesn’t help anybody.

When you get an VFSS or FEES report about a patient with dysphagia, you don’t really know how to plan appropriate therapy if all you see is “impaired pharyngeal phase.”

I know we’ve all seen reports in the past that have only documented three phases of the swallow, as if they are their own separate neighborhoods. What does that even mean? Where do treating SLPs go from reports like that? Even separate neighborhoods are all connected somehow! Like they all live in the same town right? Like they all need to know what each other is doing! (And of course it doesn’t help that our billing codes reflect the 3 phases of the swallow, but that’s another hill I’ll climb some other day)

I’ve seen things like, “Moderately impaired pharyngeal phase. Recommend intensive speech therapy.”

Excuse me while my neurons try to reboot and connect to each other in order to make something out of that…

Going even further down this rabbit hole, we all want respect. We walk the same floors as nurses, doctors, and several other allied health professionals. We need to talk like them too. We get frustrated when our physician colleagues diagnose a patient with dysphagia and put them on a puree diet with thickened liquids, but if that’s all they see our reports doing, then surely they might as well just make that recommendation for us right? Wrong.

We’re not trained monkeys, we’re speech-language pathologists that can diagnose and treat dysphagia. We want our colleagues to understand that we are a critical part of the medical team, and in order to do that our notes need to reflect that.

And last but not least, let’s not forget about our own! Our own SLP colleagues! How many times have we gotten very bare boned reports basically not even worth the paper they are written on. I know healthcare professionals are drilled in HIPAA and protecting patient information, but you can’t leave an SLP in the dark like that! What if we emphasized sharing and documenting relevant clinical information as much as we highlight HIPAA? In fact, if you look at the 7 Caldicott Principles, which are principles relating to patient confidentiality, you’ll see that Principle 7 is “the duty to share information can be as important as the duty to protect patient confidentiality.”

To further explain Principle 7: “Health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by these principles. They should be supported by the policies of their employers, regulators and professional bodies” (Department of Health, pp. 21)

In order for a patient to truly receive evidence-based therapy, we need thorough clinical and instrumental assessments. And in order for assessments to be meaningful, we need high quality documentation. Imagine that.

That’s why I was SO excited when the amazing Kelsey Day wanted to join forces to put together an all-day clinical writing course.

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My Top Book Recommendations for the Medical SLP

My Top Book Recommendations for the Medical SLP

I’ve been asked repeatedly what books I would recommend the young bucks brush up on, or maybe you had pretty craptastic dysphagia training in grad school, or perhaps you graduated 10+ years ago and you’re really getting whacked repeatedly with the EBP stick upside the head, and you feel guilty that you’re still stuck in Dr. Jeri Logemann land circa 1998, so I’ve picked out a few of my faves for you.

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