[DYSPHAGIA] documenting unusual findings on MBS

[pressmah@sjhmc.org (Pressman, Hilda)]

I usually state that the radiologist indicated "   " and then add see
radiologist's report.

-----Original Message-----
From: helen-sharp@uiowa.edu [mailto:helen-sharp@uiowa.edu]
Sent: Wednesday, December 12, 2001 5:24 PM
To: dysphagia@medonline.com
Subject: [DYSPHAGIA] documenting unusual findings on MBS


Greetings all,

I am passing along a question from a colleague regarding 
documentation.  She recently conducted a videofluoroscopic study.  She and 
the radiologist noted a structural asymmetry during the exam and the 
radiologist specified a concern about a possible (probable?) mass as the 
cause.  Radiology writes a report, but it is generally not available for 
several days.  The speech pathologist's report will therefore drive the 
referral to Otolaryngology and the swallow study report is what the 
Otolaryngologist will see prior to evaluating the patient.

Her question is how much and exactly how a speech pathologist should 
communicate about a suspicious finding in the swallow report?

She and I chatted about various ways in which we might document this 
finding.  We would both welcome ideas about how to document "suspicions" 
such as tumors, ALS, etc. in swallow reports.  Examples of wording or ways 
in which you've documented (or avoided documenting and given your concerns 
verbally) would be much appreciated!

Thanks.  I will forward your responses and we'll soon have a new recruit to 
the list!

Helen

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