Release Notes:
Data Element
Version 2010B
| Data Element Name: | Dysphagia Screen |
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| Collected For: | , |
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| Definition: | Stroke patients should be screened for dysphagia before being given any oral intake including food, fluids, or medications. |
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| Suggested Data Collection Question: | Was the patient screened for dysphagia before being given any oral intake, including food, fluids or medications? |
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| Format: | | Length: | |
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| Type: | Alphanumeric |
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| Occurs: | |
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| Allowable Values: |
Y (Yes, patient was screened for dysphagia before being given any oral intake including food, fluids or medications by mouth)
N (No, patient was not screened for dysphagia before being given any oral intake including food, fluids or medications by mouth, OR unable to determine from medical record documentation)
NC (No, patient was not screened for dysphagia before being given any oral intake including food, fluids or medications by mouth. A documented reason exists for not performing this screen.)
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| Notes for Abstraction: | Documentation in the record should indicate that an assessment of the patient’s ability to swallow was completed by a health care professional prior to oral intake of food, fluid, or medications. A screening test need not be a formal evaluation of swallowing by a speech and language pathologist, but should be a standardized method of swallowing assessment accepted by the institution.
Reasons for not performing a dysphagia screen must be explicitly documented or clearly implied by a physician, nurse practitioner, or physician assistant. If reasons are not mentioned in the context of dysphagia screening, do not make inferences unless documentation explicitly states so. All patients except those with a known history of dysphagia should have evidence of a dysphagia screen prior to any oral intake.
If dysphagia screen was offered and documentation exists that the the patient or caregiver refused, select “NC”.
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| Suggested Data Sources: |
- Progress notes
- Physician orders
- Clinician notes
- Referral/consult notes
- Flow charts
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
A variety of methods may be employed to assess swallowing status. These methods may include but are not limited to:
- Bedside swallowing assessment
- Simple water swallow test
- Burke water swallow test
- Bedside swallowing assessment
- Simple standardized bedside swallowing assessment (SSA)
- Video fluoroscopy
- Double contrast esophagoscopy
- Radio nucleotide studies
- Manometry
- Barium swallow
- Endoscopy
- Formal evaluation by a speech and language pathologist
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- Patient evaluation using the NIH/NIHSS (National Institute of Health/National Institute of Health Stroke Scale) is NOT considered dysphagia screening
- Documentation of “gag reflex present” or “positive gag” or “cranial nerves intact” without explicit assessment of swallowing is NOT considered dysphagia screening
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Dysphagia Screen
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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