Videofluoroscopic Swallow Study/Modified Barium Swallow Study Record Sheet

Imagine being in a room with your patient, a radiologist, a radiology technician, a family member, and interpreter, all the while trying to remember each trial, each dysfunction, and coming up with potential strategies to implement in real time.

When I first started completing Videofluoroscopic Swallow Studies independently, I wasn't able to keep track of all this information, SO, I tried to write everything down. The thing is, Radiologists are very busy, and depending on the patient, they don't always have the patience to wait for you to scribble out every detail. There also isn't always time to spend reviewing the images over and over. Instead of writing everything out, try simply circling the texture/consistency for each trial, location of swallow initiation, Penetration/Aspiration (PAS) score, Pharyngeal Residue, and any maneuvers that were utilized. This is the most efficient method I have found thus far. The back also includes the PAS scale and oral/pharyngeal phase dysfunction with the resulting symptom.

KEY For swallowing maneuvers: ES (Effortful Swallow), ASL (Alternating solids/liquids), DS (Double Swallow), HT (Head Turn), CT (Chin Tuck), SS (Supraglottic Swallow).

I recommend printing out this template (double-sided)and laminating it to reduce waste. I use micro felt tip dry-erase markers, clean my template after documenting, and reuse it for the next VFSS. I hope this template helps reduce your stress as much as it has for me. Enjoy! :)