If you've ever written "reduced hyolaryngeal excursion," "presents with overt signs of penetration +/- aspiration," or diagnosed oropharyngeal dysphagia from a bedside assessment — this session is for you.
Documentation isn't just an admin task. The language you use in your clinical notes reflects your reasoning and communicates your expertise. And some of the phrases we've inherited from training don't hold up under scrutiny.
This session covers the documentation pitfalls that show up most commonly in CSE notes, with the clinical rationale for why they're problematic and what to write instead:
- Diagnosing dysphagia: what you can and can't say from a bedside assessment
- Mastication: what "prolonged" actually means — and relative to what?
- Hyo-laryngeal excursion: why palpation tells us less than we think
- Swallow timing: is what you're calling a "delay" actually a delay?
- Penetration and aspiration: why these don't belong in your objective section
- What "safe" really means — and when to stop using it
Bonus resources included:
CSE Documentation Cheat Sheet. End of chapter quiz also included.