Start with the Chart: How do we find the hidden gems?
By George Barnes MS, CCC-SLP, BCS-S
Edited by Allie Mataras MA, CCC-SLP, CBIS
Chart review is one of those things that typically gets very little attention in our training, but is one of, if not the most important part of dysphagia management. What we see at the bedside and what we see on an instrumental study are just snap shots. Important snap shots? Yes. But they do not give us the whole picture. The chart, on the other hand, tells us the story of the patient. What happened, why it happened, what’s happening now, and what every discipline is doing to bring that story a happy ending. If you blink an eye or skip a page, you may miss that one thing that would have helped you solve the issue. Let’s never miss that one thing...
The Order
The doctor’s order is typically the first thing we look at and for good reason. We need to find out the details of why we are being called in. Standard protocol s/p CVA? To differentiate a diagnosis between aspiration pneumonia and edema build up with CHF? To determine if a patient needs a feeding tube? Whatever the reason may be, there is a reason and we need to find it before we do anything else.
H&P
The foundation of the chart is the history and physical (H&P). The what, the when, the how, and the where all compiled into a few short paragraphs (the longer it is, typically the more complex the case). It’s everything going on with the patient tied together with a bow. But don’t be fooled. Nobody is perfect (and that includes doctors). Some important pieces of information may be missing because of an error or simply because they were unknown at the time of admission. That’s why we look at the progress notes next.
Progress Notes
The progress notes are my favorite part of the chart. A running log of everything going on with the patient from day to day. Honestly, what could be better? If the H&P is the epilogue and back-cover summary, the progress notes are the pages in-between. It’s all the dirty details scraped together by ALL the hard-working members of the medical team. An IDT party on a page. Where the melting pot of medical professionals comes together to boil and infuse into a total greater than the sum of its parts (See? I told you it’s my favorite). While it can be an overwhelming amount of information, it’s important to cover at least the notes leading up to the evaluation and to stay on top of the attending doctor’s notes from day to day as that typically summarizes all of the new, important medical features of the patient on an ongoing basis. Other notes you might want to pay particular attention to are prior speech notes, nursing, respiratory, infectious disease, GI, neurology, dietary, therapy, and any other specialist that may be of interest to the case. I know, time is of the essence, but think about all the time you could be saving by finding that most important piece of information from the get-go instead of guessing aimlessly like a dart throwing chimpanzee. Not every part of every note has to be read either. Spending 20 minutes re-reading the copied over history might not be worth your time. Use your judgment. Jump to the highlighted parts to get a quick glance at the overall picture if you’re in a time crunch (as we almost always are in the medical setting). Keep an eye out for predisposing risk factors for aspiration and pneumonia (i.e. CVA, degenerative diseases, respiratory conditions, etc.). The more you practice this, the more easily you’ll be able to spot those gems.
Vitals
Is the patient stable enough to work with at this time? Taking a look at the vitals will give us this answer in the quickest way. Vitals include the patient’s temperature, respiratory rate, SpO2, Heart rate, and blood pressure. Not stable? Why not? Investigate further with the team and by going through the chart to get the rest of the story. Know before you go to avoid making assumptions about the patient’s status and medical stability.
Imaging
Didn’t think you had x-ray vision, did you? You do. So use it. Not only can we see into the depths of the human body with medical imaging, but we have a specialist (the radiologist) to summarize the findings for us. Nice right? Yes, sometimes the terms can be confusing. This resource may be able to help guide you. Google is also an SLP’s best friend. Just make sure the source is reputable. Don’t give up! The more you research those obscure (and often abstract) terms, the clearer the “image” becomes.
Medications
Ah, the dreaded med list. At times, it can be pages long and usually full of bizarre sounding names that can take more time to pronounce than to figure out what they actually do (thinking about Dimethylamidophenyldimethylpyrazolone). What’s important is not being an expert, but to slowly get familiar with the names, their purpose, and how they may impact dysphagia. What helped me the most was going through the med list and looking up a couple of unfamiliar names each time. Once you get familiar with most of them, you’ll want to find the ones you don’t recognize. It may take a few months, but over time you’ll begin to understand the med list better and better. You’ll see a lot of the same meds popping up time and time again, but most importantly, you’ll be able to connect the dots of what’s going on with the patient and how it might be related to a specific medication. Meds can impact dysphagia in a myriad of ways, including motor function (e.g. CNS depressants), GI motility (e.g. anti-psychotics), and taste and smell (e.g. anticholinergenics). Shedding light on these meds and their potential impact on the patient can change the whole clinical picture.
Lab work
I equate lab work to that green screen in The Matrix which some people can look at and understand without thinking twice while the less-experienced clinician just sees a meaningless array of numbers akin to ancient hieroglyphics. I’m no Neo, but as swallowlogists, there are a few really important ones we should be mindful of (e.g. WBC, BUN, and ABG). The lab is a complex, living creature that moves and changes each day which requires ongoing study. Best to ask the medical experts when we see something abnormal before we jump to conclusions. That doesn’t mean we can’t have a good foundation of knowledge so we know what we are looking at though. This understanding will help give us a snap shot of what’s going on, what’s changing, and its meaning in relation to the patient’s function with eating and drinking. The best source I have come across on this topic is from the fantastic Karen Sheffler of SwallowStudy.com.
Allergies
Last, but NOT least, check if the patient has any food allergies. This may sound obvious, but with so many other incredibly important pieces of the puzzle to look at this can go unnoticed. We are responsible for helping our patients recover or at the very least preventing harm. Making sure the patient is not allergic to any of our trials is a fast and easy way to do just that. It’s also a reminder that everything counts in the chart review. You can do 100 chart reviews in a week and not find one allergy, but on the 101st you could catch something that may save a terrible situation from occurring.
As incredible a resource as the chart is, it does not give us all the answers. On the contrary it often leaves us with more questions than we started with. We may not always find what we are looking for, but it is the best platform to jump off of in order to dive head first into the evaluation process. We may also find things that need clarifying by the team. A short discussion with the IDT is worth 1000 words in the chart so never neglect picking up the phone or walking down the hallway to connect with your colleagues. But first, start with the chart. Review it the same way every time to promote muscle memory and, eventually, a seamless and efficient routine. Most importantly, don’t skip any steps. You never know when that step your skipping is the hidden gem you’ve been looking for the whole time. The chart is our road map just waiting to be opened up at the beginning of a long journey and returned to whenever we get lost or forget where we are going. This is even more important on a highway that goes up mountains, underground, and swerves around turns without notice. Sometimes the road stops altogether forcing us to take alternative routes. What’s at the end of the road is a solution for the patient just waiting to be found. And it all starts with the chart.
