Get the free Video Fluoroscopic Swallow Study Intake Form (SLP)

Video Fluoroscopic Swallow Study Intake Form (SLP) Patient Name Referring Physician Anticipated Date of Study Current Diet Primary Speech Pathologist (SLP) Name Please Circle One: Home Care / Outpatient

How to fill out video fluoroscopic swallow study

How to fill out video fluoroscopic swallow study

1. Prepare the patient by explaining the procedure and obtaining informed consent.
2. Position the patient upright in front of the fluoroscopy machine.
3. Administer barium sulfate mixed with water or a barium contrast agent orally to the patient.
4. Guide the patient to swallow the barium mixture while taking live X-ray images using the fluoroscopy machine.
5. Observe the swallowing process and assess any abnormalities or difficulties.
6. Record the video fluoroscopic swallow study for future reference and analysis.
7. After the study is complete, provide the patient with post-procedure instructions and any necessary follow-up appointments.
8. Clean and sanitize the equipment used for the procedure.

Who needs video fluoroscopic swallow study?

1. Individuals who experience difficulty or pain while swallowing (dysphagia)
2. Patients with a history of aspiration pneumonia or lung infections
3. Those who have undergone surgery or radiation therapy for head and neck cancer
4. Individuals with neurological conditions that affect swallowing function (e.g., stroke, Parkinson's disease)
5. Patients with suspected or known structural abnormalities in the throat or esophagus
6. Individuals with gastroesophageal reflux disease (GERD) or other gastrointestinal disorders
7. Patients with unexplained weight loss or malnutrition

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What is video fluoroscopic swallow study?

Video fluoroscopic swallow study is a procedure used to evaluate swallowing function by using real-time x-ray technology.

Who is required to file video fluoroscopic swallow study?

Patients who are experiencing swallowing difficulties may be required to undergo a video fluoroscopic swallow study.

How to fill out video fluoroscopic swallow study?

A licensed medical professional will administer the study by having the patient swallow various consistencies of liquid or food while being monitored by a fluoroscope.

What is the purpose of video fluoroscopic swallow study?

The purpose of a video fluoroscopic swallow study is to assess the patient's ability to swallow safely and effectively, as well as to identify any potential issues or abnormalities.

What information must be reported on video fluoroscopic swallow study?

The report should include details on the patient's swallowing ability, any difficulties or abnormalities observed during the study, and recommendations for treatment or further evaluation.