SLP Session Note
Created by
Jill Fraser
Specialty
Speech Pathologist
Last edited
10/20/2026
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0 times
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About this template
A reusable template for documenting speech-language pathology sessions, including the patient’s reported concerns, session observations, and recommendations. It supports tracking speech, language, cognitive-linguistic, and behavioral findings without pre-populating any clinical information.
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Subjective
- Pt c/o persistent coughing on thin liquids and mild unintentional wt loss (2.5 kg over 1 mo). Co-treatment session today with SLP and RD to evaluate swallowing function and optimize nutritional intake per IDDSI framework.
- PMH: L MCA ischemic stroke (12/02/2026), HTN, dyslipidemia. PSH: Laparoscopic cholecystectomy (2018).
- Meds: clopidogrel (Plavix®) 75 mg PO daily, perindopril (Coversyl®) 4 mg PO daily, rosuvastatin (Crestor®) 20 mg PO daily, cholecalciferol (Vitamin D3) 1,000 IU PO daily.
- Lives with spouse in a 2-storey home in Halifax; spouse manages meal prep. Retired teacher, non-smoker, nil EtOH.
- Allergies: Penicillin (urticaria), sulfonamides (rash).
Observations
- Mild-mod spastic dysarthria characterized by imprecise consonants and reduced rate of speech; speech 85% intelligible in known context. Receptive and expressive language WNL.
- Cooperative, motivated, and attentive throughout the 45-min session. Good insight into swallowing deficits; mild frustration noted with thickened liquid textures.
- Oral motor exam: Mild R facial weakness and lingual deviation to R on protrusion. Delayed pharyngeal swallow initiation observed during trials. Silent aspiration suspected on 10 mL thin liquid trials (wet vocal quality post-swallow); tolerated IDDSI Level 2 (mildly thick) liquids and IDDSI Level 5 (minced and moist) solids with 0% overt s/s of aspiration using chin tuck strategy.
- Alert and oriented x4. Followed multi-step safe swallowing instructions independently; intact working memory and executive functioning for compensatory strategy carryover.
- Current intake inadequate per 24-hr recall (~1,100 kcal/day) secondary to oral phase fatigue during meals.
Recommendations
- STG (2 wks): Pt will safely consume IDDSI Level 5 solids and IDDSI Level 2 liquids utilizing chin tuck posture with 0% overt signs of aspiration across 3 consecutive meals. LTG (6 wks): Pt will safely downgrade to thin liquids (IDDSI Level 0) and maintain stable body weight.
- Implement IDDSI Level 5 (minced and moist) diet and IDDSI Level 2 (mildly thick) liquids. Utilize chin tuck on all liquid swallows, small bolus sizes (5 mL), and cyclic ingestion (alternating solids and liquids) to clear pharyngeal residue.
- Complete Masako (tongue-hold) maneuver, Mendelsohn maneuver, and effortful swallow: 10 reps each, PO TID prior to meals.
- F/U SLP session in 1 wk (01/04/2026 at 10:00 AST). Referred for instrumental VFSS to r/o silent aspiration. F/U with RD in 2 wks for wt check and intake reassessment.
- Add high-protein, high-calorie ONS (Ensure® Plus, pre-thickened to IDDSI Level 2) 235 mL PO BID between meals to meet estimated nutritional needs (1,800 kcal, 85 g protein/day). Small, frequent meals recommended to mitigate fatigue.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.