"Write the vision, and make it plain upon tables, that he may run that readeth it."
—Habakkuk ii. 2 (605–597 BC)
As practicing clinicians, we are entrusted to be guardians, developers, and, perhaps most importantly, conduits, of our collective science. We know that physicians and other health care providers request our services with the expectation that we will, as precisely as possible, identify and enact effective treatment for swallowing disorders. However, the value of even the most effective and artfully applied assessment is reduced without skillful, concise, and accurate communication of our activities.
Health care is often initiated in an information vacuum. For each new patient, the physician initiates an information-gathering mission to solve the problem presented by the patient. For the physician, a carefully constructed and maintained medical record is the primary tool for carrying out the task of patient care. If the system is efficient, the consultative process will ensure that relevant information is collected, considered, and acted upon in an organized manner.
Yet, physicians continue to depend on fallible, idiosyncratic inputs from fellow physicians, nursing staff, and other allied clinicians. Medical records are notorious for incomplete and widely varying layout, design, and substance. Often the poor quality of the record reflects disarray in the decision-making and problem-solving process and can prevent the timely and accurate application of treatment or other intervention. Successful execution of medical decisions requires high-quality writing and reporting skills from the specialists who are consulted.
When a clinician receives a consult to assess a patient's swallow function, the clinician should consider how the referring physician would gain from the interaction. A well-formulated consultation makes it clear that physicians are looking for help and direction as well as a direct response to any question posed in the consultation, such as "Can this person safely eat?" In our zeal to report specific findings we think are relevant, we may dismiss the physician's explicit question, leaving the physician feeling like something's missing. Their primary desire is to receive the expression of an opinion related to their question, as well as the presentation of a workable functional diagnosis. The physician reader also will look for a list of the limitations of the examination, if any existed. It may be important that a patient was unable to complete the examination because of fatigue or positioning problems. These seemingly incidental details are sometimes a revelation to the consulting physician and can form a basis for intervention.
There are times when the consultation leaves the clinician confused. I recall a consultation that simply read: "Patient with aphasia. Determine need for PEG." A phone call or note should always follow a confusing consult to make sure that your full effort is applied to answering specific questions and not wasted in figuring out the reason for the consultation.
How Should the Report Be Written?
Good writing is succinct, accurate, clear, and unambiguous. Your goal should be to grab the attention of the reader and convey a message that elicits a response. Brevity is preferable to too much detail. Experienced readers often note that the length of a report is inversely related to the self-assurance and grounding of the writer. Further consideration should be given to the value of the report as a base upon which skilled clinicians with specialized knowledge can carry out and be reimbursed for appropriate treatment. The form and style of the report can vary while still satisfying the aforementioned attributes. Checklists and narratives, or a combination of the two, are used most frequently.
Checklists come in a dizzying variety and are best used as a "job aid" to guide administration of the instrumental or clinical examinations. They are useful for verification of procedures, ensuring that nothing is skipped or forgotten, and to archive findings. Checklists appear to be time-savers and, for some, are the endpoint of the assessment and reporting process. Unfortunately, the benefit of quick recording leads to imprecision. The checklist often does not match the wealth and complexity of the findings available to a vigilant observer. Further, for someone unfamiliar with the recording process, deciphering a checklist is cumbersome and sometimes impossible. If a checklist is used, it is best to add a narrative summary to assist the reader in the interpretations of the findings.
The narrative report provides a more traditional recounting of the assessment and typically comprises several sections: introductory statement, description of examination parameters, objective listing of exam results, statement relating the writer's impression of the findings, and a listing of recommendations along with information relating patient education.
Introductory Statement. The introductory statement may include the patient's history, current subjective complaints, and the reason for consultation. In this section the writer may discuss the pertinent medical and surgical history that is believed to be related to the swallowing disorder. It is important to list all of the known disease processes related to the dysphagic symptoms, with special attention to those with recent onset or those congruent with exacerbations of the dysphagia. The patient's chief complaint and secondary complaints related to dysphagia should be carefully recorded here (e.g., "I choke every time I drink coffee.").
If pertinent history is not provided by the consulting physician, its absence should be noted in the introductory section. The absence of this information may reveal diagnostic uncertainty by the consulting physician and allow for greater leeway in expanding on your opinion of the case in the impressions section.
The introductory statement should detail the duration of signs and symptoms. It may be relevant to relate the patient's current weight, height, and body mass index with the patient's premorbid, or typical, weight. Findings from previous swallow assessments and the findings of the most recent clinical swallowing assessment should be included to give some perspective.
As a rule, the introductory statement should be short. In the example entry above, we review the history, signs, and symptoms of a patient with a complicated history of acute care. Our job is to succinctly describe his history and current presentation in a snapshot format. For reimbursement of instrumental examinations, documentation must verify that the pathophysiology of the dysphagia could not be demonstrated through the clinical examination and that an objective, instrumental visualization was necessary.
ExaminationParameters. In this section you may describe how the examination was conducted. Details—such as the type and volume of consistencies presented to the patient, the positioning of the patient, or X-ray projections employed to achieve the appropriate view—can be listed. This allows the first-time reader to better understand the scope and nature of the examination.
Results. This section is reserved for objective statements only. State only what was observed.
One of the initial statements should relate the normalcy or deviation of the anatomy of the swallowing mechanism. Attempt to describe the physiology of respective stages of the swallow as thoroughly as possible. Clinicians often report the presence or absence of aspiration or penetration in a binary fashion. Instead, attempt to enhance the report by using a reliable scale such as the Aspiration/Penetration scale (see Rosenbek et al.). Using this scale allows the clinician to objectively describe the degree of aspiration or penetration and the patient's spontaneous response. Alternately, an exact description of the penetration or aspiration should be entered with attention to the patient's reaction.
As the exam is conducted, interventions may be attempted. Describe the type of intervention and the patient's response to it. For instance, was a chin tuck attempted? If so, how was the physiology of the swallow affected?
It may be helpful to describe the events in sequence; for example, oral stage events first, followed by pharyngeal stage events, followed by upper esophageal and esophageal events. When a particular stage is completed without obvious impairment, it should be stated as such.
The results section is a "just the facts" report, where events are described without interpretation. Maintaining objectivity is particularly difficult when describing events related to a "delayed" swallow. The conventional use of the term "delay" was reserved for situations where a longer than normal transition from the oral stage to the pharyngeal stage was observed. Today, this term varies greatly in its meaning. Some practitioners use terms such as "delay," "pharyngeal delay," "delayed pharyngeal response," "spillage," "premature spillage," or "leakage" interchangeably. Current thinking would suggest there is a considerable amount of variability in these measures, even in normal subjects, and that these terms may not accurately reflect the observed event.
To maintain objectivity, instead of using statements such as "pharyngeal delay was severe," use statements with language that does not assign a judgment of severity, such as "The transition from oral to pharyngeal stages averaged five seconds for thin liquid swallows." An additional mention of the depth of the bolus in the pharynx or the proximity of the bolus to the airway before the onset of the swallow would be useful here. Similarly, swallows should not be described as "weakened" or "weak" in the results section. Reserve determination of weakness for the impression section. It is advisable to report only the observable effect of the biomechanical forces on the bolus. The location and volume of residuals also should be noted.
In order to create a trail from the observed event to the inferred disordered physiology, certain concrete statements must be made. Depending on the instrumentation used, a myriad of physiologic movements can be observed and reported. For instance, the clinician will have the opportunity to objectively report that laryngeal elevation or epiglottic retroflexion were incomplete or absent. The writer also may choose to use a reliable rating scale that allows for the objective reporting of events, such as the Aspiration/Penetration Scale (see Rosenbek et al.). A range of normal findings also could be reported, but the list may be too far-reaching for the reader. If the physiologic parameters of an entire stage were normal, the reader would appreciate a brief, rather than an exhaustive, description of the normal findings.
Impression. The impression section is reserved for subjective statements. It is dedicated to the integration of information that was objectively observed and reported in the results section. The reader expects a full analysis of what can be inferred from the observations, with a diagnostic statement and rationale to defend the analysis.
Now is your chance to provide a helpful service to the physician who has sought your advice. As you integrate the findings, you are safe to render statements that include such words as "weakened" or "delayed." Tell the reader why you think weakness contributes to the observable events or why "leakage" may contribute to aspiration during the transition from oral to pharyngeal stage. An assignment of severity and a rendering of prognostic statements can be attempted with specific caveats regarding safety.
Reimbursement is dependent on your ability to demonstrate that a skilled service, requiring specialized knowledge and training, was performed. Your demonstration is limited to the language that can be generated in your report. The report should contain key words that signal the specialized knowledge and training of a professional. According to Medicare guidelines, the words "evaluated, analyzed, modified, trained, and designed" are expressions that would indicate reimbursable activities. On the other hand, there are words to avoid, such as "noted, observed, and monitored." It is suggested that a nonprofessional could note difficulties or observe behaviors.
The impression section should include a solid identification of the disordered physiology and the specific swallowing stage that is affected. A treatment plan should be suggested to address the disorder. The clinician should describe in exact terms the potential for poor outcome should treatment not be provided. Specifically, the clinician should relate the potential for the development of dehydration, malnutrition, and/or the risk for recurring events of aspiration.
The duty of the writer is to identify the impaired physiology that contributes to the dysphagia, identify the risk for poor outcome associated with the dysphagia, and connect a skilled intervention to the elimination or control of the high-risk outcome. The intervention may be habilitative rather than rehabilitative in nature. Patients with chronic or progressive neurologic disease may not exhibit the potential for rehabilitation, but may be helped by offering short-term instruction in positioning, diet, or behavioral modifications in feeding. In some cases, reimbursement can be tied to expanding the range of foods available to these patients, thereby facilitating greater PO intake, reducing the risk for malnutrition or dehydration, and improving their quality of life.
Recommendations. Because we are being consulted for an opinion, our intent is not to give orders, but to present our recommendations in a way that allows the physician to consider different options for management. We are petitioning the physician to strongly consider our suggestions without demanding such. I would suggest adding a statement that reflects this intention, before giving the recommendations. Use a simple proviso, such as: "If consistent with all other care, the following recommendations can be considered…" This allows physicians to exercise some "wiggle room" in applying the recommendations and allows them to shape the management given all of the constraints that may need to be considered.
Recommendations should directly respond to the consulting physician's interest in requesting the consult. If the physician has asked for specific advice regarding a safe diet, and you can confidently make a recommendation, do so. If you cannot, state this very directly. Our intention is to assist in the decision-making process. If we do not directly address the question asked of us in the consultation, we have failed.
In the example below, we are recommending the provision of skilled services for a patient transitioning from enteral to oral feeding. To enhance the likelihood of reimbursement, clinicians should avoid language in their recommendations that suggests the provision of unskilled services, such as routine or repetitive observations or cueing of behaviors.
Patient Education. Describe your review of the feeding or exercise guidelines and safety issues. Make sure you indicate the patient's level of understanding of specific instructions or directives. If the patient is incapable of receiving the information, be sure to document information that you have provided to a caregiver or other surrogate. Be sure to list any barriers to education and how they were overcome or compensated for.
Many of us associate our image with the effort and toil that is put forth as we directly engage the patient in our charge. But too often our image is established by our written communication rather than our personal interaction. The quality of our response to a consultation may be the single act that carries a positive impression and ensures that our services are sought in the future.