Speech Therapy Chart Review
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1
2Speech Therapy Chart Review
NAME:
DATE OF CHART REVIEW:
DOB:
REASON FOR MOST CURRENT HOSPITALIZATION:
GENDER:
M
F
GLASSES:
Y
N
HEARING AIDS:
Y
N
Left
Right
PREMORBID STATUS:
REASON FOR REFERRAL:
MEDICAL HISTORY/ DIAGNOSIS:
Stroke/ CVA
Multiple Sclerosis
Parkinson’s
Amyotrophic
Huntington’s Chorea
Disease
Lateral Sclerosis
Right or Left Sided
Alcohol or
Hip Fracture
Seizure Disorder
GERD
Paresis/ Paralysis
Substance Abuse
Dementia
Lung Disease or
Recurrent
Urinary Tract
Previous Swallow
COPD
Pneumonia
Infections
Study
Respiratory Failure
Altered Mental
Head and/or Neck
Head Injury
Other Neurological
status
Cancer
Disease / Problems
COGNITIVE STATUS:
Agitated
Alert
Cooperative
Confused
Disoriented
Lethargic
Non-Verbal
Uncooperative
Follows directions
Oriented
PATIENT’S TOLERANCE ON CURRENT DIET / SYMPTOMS OF DYSPHAGIA:
Choking/ Gagging
Coughing
Reflux
Edentulous
Fever
Food sticking in mouth or throat
Loose Dentures
Drooling/
Dehydration
Increased secretions
Resistance to eat or drink
Throat clearing
Shortness of
Changes in diet
breath
Increased time to consume meal
Wet vocal quality
Weight loss
Respiratory probs.
Nutrition
Pocketing food
Spillage of liquids
Taking a long time
Patient complaint
concerns
or food
to swallow
RESPIRATORY STATUS:
WNL
Audible
Continuous O
Suctioning
Tracheostomy
2
Congestion
(note status of cuff &
if tracheostomy
Ventilator
Lung sounds
Rales or Rhonchi
Recent Intubations
speaking valve)
dependent
CURRENT DIET:
Regular
Mechanical Soft
Finely Ground
Pureed
Low salt
Low cholesterol
Low sodium
Regular liquids
Nectar thick liqs.
Honey thick liqs.
Pudding thick liqs.
Low potassium
Other:
MEDICATIONS:
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