Site Outpatient Dysphagia Clinic Referral Form Peter Lougheed Centre 3500 - 26th Avenue NE Calgary AB T1Y 6J4 Phone 403-943-4941 Fax 403-943-4520 Patient Contact Information Phone Fax Does this patient have a legal guardian Yes No If Yes Language Medical History relevant to swallowing problem Pulmonary / Respiratory status Neurological diagnosis Cancer Treated with radiation Other Medications History/Duration of Swallowing Problem/Reason for Ref.
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How to fill out the Dysphagia Clinic online
Filling out the Dysphagia Clinic referral form is an essential step for individuals experiencing swallowing difficulties. This guide provides clear and user-friendly instructions to help you complete the form accurately and efficiently.
Follow the steps to complete the referral form effectively.
- Press the ‘Get Form’ button to access the Dysphagia Clinic referral form and open it in your preferred editor.
- Fill in the patient contact information, including the phone and fax numbers. Indicate whether the patient has a legal guardian and if an interpreter is required, specifying the language if applicable.
- Provide details on the medical history relevant to the swallowing problem. This includes information on pulmonary or respiratory status, neurological diagnosis, and a history of cancer, with follow-up questions on treatment and other relevant conditions.
- Outline any medications the patient is currently taking, if applicable. This section is crucial for the clinic's understanding of the patient's overall health.
- Describe the history and duration of the swallowing problem, noting any recent changes in swallowing status or documented issues like silent aspiration, weight loss, temperature spikes, or pneumonia.
- Specify the current method(s) of feeding and nutrition, indicating if the patient is nothing by mouth or using feeding tubes. Include details about any modified texture diets.
- Attach any recent diagnostic reports, including dates for chest X-rays, upper GI studies, CT scans, or MRI results as required. Ensure all dates are formatted correctly.
- Indicate if the patient is being followed by any clinics or specialists, and attach recent consultation reports if necessary.
- List any recent hospital admissions, including the date, location, and admitting diagnosis as applicable.
- Provide referral source information, including the referral source name, specialty or professional designation, phone number, signature, and date.
- Ensure all sections of the referral form are completed, including a signed diagnostic imaging requisition for a modified barium swallow. Review the form for completeness to avoid delays in processing.
- Once completed, save your changes, download, print, or share the form as necessary.
Start filling out the Dysphagia Clinic referral form online today to ensure timely access to necessary care.
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What is the standard assessment for dysphagia?
The standard assessment for dysphagia typically consists of a clinical swallowing evaluation followed by instrumental assessments like a videofluoroscopic swallow study. These comprehensive evaluations determine the severity of dysphagia and help develop a personalized care plan. A visit to a Dysphagia Clinic ensures access to the latest assessment methods and expert guidance.
How to do a dysphagia assessment?
To perform a dysphagia assessment, begin with a detailed patient interview to understand their swallowing history. Follow this with a clinical evaluation that may include a bedside swallowing test and possible imaging studies. Enrolling in a Dysphagia Clinic can enhance the accuracy and comprehensiveness of the assessment process.
What are the 7 main outcomes that people with dysphagia care about?
Individuals with dysphagia commonly care about safe swallowing, the enjoyment of food, nutrition adequacy, prevention of aspiration, maintenance of social interactions during meals, overall quality of life, and proper management of their condition. Addressing these outcomes is essential and a Dysphagia Clinic can support patients in achieving their goals.
What is a dysphagia clinic?
A Dysphagia Clinic is a specialized facility focused on diagnosing and treating patients with swallowing difficulties. These clinics bring together healthcare professionals who use advanced techniques to evaluate and manage dysphagia. Patients benefit from tailored treatment plans that address their unique swallowing challenges.
How to assess a patient with dysphagia?
Assessing a patient with dysphagia involves observing their eating habits, noting any difficulties while swallowing, and performing tests with various food textures. Healthcare providers may also use imaging techniques to analyze swallowing function. A Dysphagia Clinic offers targeted assessments for a thorough understanding of individual needs.
How to do a dysphagia screening?
To conduct a dysphagia screening, start with a review of the patient's medical history and any prior swallowing difficulties. Next, observe the patient while they consume small amounts of food or liquid to assess for signs of swallowing difficulties. A visit to a Dysphagia Clinic can provide a structured setting for a detailed screening process.
What items should be included as part of a dysphagia screening?
A thorough dysphagia screening should include evaluation of the patient's medical history, a visual examination, and assessment of the swallowing process with various food and liquid textures. Healthcare professionals often recommend including tools for scoring swallowing abilities. Utilizing a Dysphagia Clinic can ensure a comprehensive approach to these screenings.
How do nurses assess dysphagia?
Nurses play a crucial role in assessing dysphagia by observing patients during eating and drinking. They look for signs like coughing, choking, or difficulty swallowing. This initial assessment often leads to a referral to a specialized Dysphagia Clinic for further evaluation.
What specialist helps with dysphagia?
Multiple specialists help with dysphagia, including speech-language pathologists, gastroenterologists, and ENT doctors. Each plays a unique role in assessing and improving your swallowing abilities. A Dysphagia Clinic provides a one-stop solution, where these experts collaborate to offer you coordinated care. This ensures you receive comprehensive support throughout your treatment journey.
What can an ENT do for dysphagia?
An ENT specialist can evaluate and treat issues related to the throat and upper airway that may contribute to dysphagia. They perform examinations, recommend imaging studies, and suggest therapeutic options to improve swallowing safety. At a Dysphagia Clinic, an ENT evaluates your condition alongside other specialists to create an integrated treatment plan tailored to you. This holistic approach helps maximize your recovery.
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