Free Bedside Swallow Evaluation Template
Bedside Swallow Evaluation
The Bedside Swallow Evaluation (BSE) is a clinical assessment used to evaluate a patient's swallowing function at the bedside. This evaluation is crucial for identifying dysphagia, assessing aspiration risk, and guiding appropriate interventions to ensure safe oral intake. The BSE involves a systematic assessment of various components of swallowing, including oral motor function, sensory awareness, and coordination of swallowing reflexes.
Patient Information
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Name |
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Age |
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Gender |
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Medical Record Number |
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Date of Evaluation |
Clinical Presentation:
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Chief Complaint |
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Relevant Medical History |
Observation
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1. Oral Mechanism Examination |
Yes |
No |
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Lip Closure |
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Tongue Mobility |
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Palatal Elevation |
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Laryngeal Elevation |
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Presence of Oral Residue |
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2. Cough Reflex |
Yes |
No |
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Spontaneous Cough |
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ough After Swallowing |
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Ability to Clear Secretions |
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3. Voice Quality |
Yes |
No |
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Wet/Gurgly Voice |
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Hoarseness |
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Vocal Effort |
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4. Oral Sensation |
Yes |
No |
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Sensory Awareness |
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Gag Reflex |
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Ability to Detect Food in Mouth |
Swallowing Trials
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1. Liquid Consistency |
Yes |
No |
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Volume |
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Ability to Initiate Swallow |
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Presence of Coughing |
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Signs of Aspiration |
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2. Pureed Consistency |
Yes |
No |
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Texture Tolerance |
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Mastication Ability |
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Bolus Formation |
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Swallowing Coordination |
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3. Solid Consistency |
Yes |
No |
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Texture Tolerance |
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Mastication Ability |
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Bolus Formation |
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Swallowing Coordination |
Overall Assessment
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Overall Swallowing Safety |
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Recommendations/Interventions |
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Comment/Feedback |
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Provide any additional comments or feedback regarding the evaluation process or the patient's swallowing function. |
[Evaluator's Signature Over Printed Name]
