Swallowing (dysphagia) assessment report template for speech and language therapists

A swallowing assessment report is the document a speech and language therapist sends to the referring doctor after assessing how a patient eats, drinks and manages saliva. It sets out the mechanisms involved, the risk observed with each texture, the adaptations proposed and the care plan. This page starts from the French and Belgian frameworks; the structure works wherever you practise.

The framework

France: what the NGAP says

The NGAP in force from 1 January 2026 (title IV, chapter II, article 2) lists the assessments discussed here under "Bilans avec compte rendu écrit obligatoire" (assessments with a mandatory written report). It adds that for a renewal assessment "la cotation du bilan est minorée de 30 %" (the fee is reduced by 30%). No line is called "dysphagia assessment". The lines that may cover a swallowing assessment are these, quoted as written.

• Bilan de la déglutition et des fonctions vélo-tubo-tympaniques (swallowing and velo-tubo-tympanic functions): 26 AMO
• Bilan des fonctions oro-myo-faciales et de l'oralité (oro-myofacial functions and orality): 34 AMO
• Bilan des troubles d'origine neurologique (disorders of neurological origin): 40 AMO

For therapy, the NGAP separates "Rééducation de la déglutition dysfonctionnelle" (dysfunctional swallowing, 9.8 AMO per session), "Rééducation des dysphagies" (dysphagia, 12.8 AMO), "Rééducation des anomalies des fonctions oro-myo-faciales et de l'oralité" (13.5 AMO) and, for patients with neurological conditions, an act that explicitly includes "des fonctions oro-myo-faciales" (15.7 AMO, or 15.6 AMO for neurodegenerative conditions). The text also states that the codes in this article cannot be combined with each other.

Which line to use depends on the referral and the clinical context. We suggest choosing the one that best matches the real reason for the assessment, stating it at the top of the report and, if in doubt, checking with your professional body or your local fund. Fee rules are covered in our French page on AMO coding and the NGAP in 2026. When therapy follows, the NGAP says the report includes the therapy goals and the number and type of sessions the speech therapist sets.

Belgium: INAMI article 36

The consolidated text of article 36 (in force from 1 August 2024) includes code "706016-706086 Bilan d'évolution pour dysphagie" (progress assessment for dysphagia, R 35, so during treatment) and states that for patients covered by § 2, e) approval may be given for up to 65 individual treatment sessions of at least 30 minutes. Referral for dysphagia is limited to certain medical specialties. We could not read the definition in § 2, e) in the version consulted, so we suggest checking the exact criteria in the current consolidated text and stating them clearly in the report attached to the request. See also our pages on the Belgian speech therapy nomenclature (article 36) and the INAMI request. The Belgian text calls the therapist a "logopède".

Switzerland and elsewhere

Coverage rules vary by insurer and canton: we suggest keeping the same report structure and adding the referral and insurer details at the top. For UK conventions, see our speech and language therapy report guide for the UK.

Report template to copy

Keep the order of sections: the doctor reads the summary first, the care team looks for the recommendations. Replace the brackets.

1. Header

• Therapist: [name, address, registration number]
• Patient: [name, date of birth], living situation: [alone at home, with carer, care home, hospital ward]
• Referrer: [name, specialty], referral date: [ ], written reason: [ ]
• Type: [initial or renewal], fee code used: [ ], assessment date(s): [ ]

2. Reason for referral and complaint

• Patient's complaint, in their own words: [ ]
• Concerns from family or staff: [coughing at meals, longer meals, weight loss, refusing drinks]
• Self-report questionnaire, if used: [name, version, result as scored by the therapist]

3. History

• Main condition and date: [stroke, Parkinson's disease, MND, head and neck cancer, presbyphagia]
• Relevant history: [chest infections, intubation, tracheostomy, neck surgery or radiotherapy, reflux]
• Medication that may affect swallowing or alertness: [from the prescription provided]
• Reported nutritional status: [weight, change, supplements]
• Current diet: [textures, thickener, feeding route, meal duration, help needed]
• Teeth and dentures: [ ]
• Previous assessments: [FEES, videofluoroscopy, with date and the doctor's conclusion]

4. Assessment conditions

• Alertness, understanding of instructions, fatigue: [ ]
• Posture: [upright at 90 degrees, wheelchair, bed] and head position: [ ]
• Breathing at rest: [ ], support: [oxygen, cannula]

5. Oral structures and function

• Lips, tongue, cheeks, soft palate, jaw: shape, tone, strength, range, symmetry
• Oral and facial praxis on command and on imitation
• Oral sensation and reflexes (gag, voluntary cough)
• Saliva management: [drooling, pooling, spontaneous swallows]
• Voice and voluntary cough: [quality, loudness, cough strength]

6. Oral trials

One line per trial: texture (IDDSI level), volume, utensil, posture, oral time, swallow onset, signs during and after, outcome.

• Trial 1: [ ]
• Trial 2: [ ]
• Trials not done and why: [stopped on a warning sign, fatigue, refusal]

7. Summary and clinical impression

• Phases affected: [oral preparatory, oral, pharyngeal] and likely mechanisms
• Textures managed safely, textures at risk, textures not tested
• Limits of the bedside assessment: [silent aspiration not excluded]

8. Therapist's recommendations

• Recommended textures (IDDSI levels for food and drinks): [ ]
• Posture and positioning: [ ]
• Strategies and manoeuvres: [ ]
• Monitoring for staff or carer: [signs to report, weight, hydration]
• Suggestions for the doctor: [instrumental assessment, dietitian review, ENT or neurology opinion]

9. Care plan

• Goals: [ ]
• Number, type and frequency of sessions: [ ]
• Review date: [ ]

10. Signature and recipients: [referring doctor, GP, care team with the patient's agreement]

Textures, tools and warning signs

Name textures with IDDSI

The IDDSI framework describes eight levels, 0 to 7: drinks from 0 to 4, foods from 3 to 7. The names below are those used in the IDDSI patient handouts.

• Level 0: Thin
• Level 1: Slightly Thick
• Level 2: Mildly Thick
• Level 3: Moderately Thick (drinks), Liquidised (foods)
• Level 4: Extremely Thick (drinks), Pureed (foods)
• Level 5: Minced and Moist
• Level 6: Soft and Bite sized
• Level 7: Easy to Chew, Regular

Writing "jelly water" or "mashed" leaves every kitchen to interpret. Writing "drinks level 2, food level 5" gives an instruction the kitchen, care staff and family all read the same way. IDDSI advises against changing its descriptors, so use the names as they are.

Tools: only cite what you used

The EAT-10 is a ten-question self-report screening tool. Its French version has been validated (Lechien et al., 2019). If you use it, record the version and the result as you scored it, without reading more into it than the tool allows. For any scale or checklist, we suggest noting the exact name, version and conditions, and flagging any adaptation.

Warning signs to document

• Coughing or throat clearing during or after the swallow
• Wet voice after intake
• Nasal regurgitation, food sticking, oral residue after several swallows
• Breathlessness, drop in alertness, growing fatigue during the meal
• In the history: weight loss, longer meals, repeated chest infections, unexplained fevers

No warning signs during the trial does not prove there is no aspiration: some is silent. Instrumental assessments (FEES, videofluoroscopy) are requested from the doctor. The report can suggest them and explain why; it does not order them.

Completed example (fictional patient)

Patient: Mrs Odile R. (fictional), 74, lives at home with her husband. Referrer: neurologist, reason "swallowing difficulties, Parkinson's disease, assessment and therapy if needed". Initial assessment.

Complaint: "I cough when I drink too fast." Her husband reports longer meals since the winter and a 3 kg weight loss over six months. EAT-10 (French version) completed by the patient: 14, scored by the therapist.

History: Parkinson's disease diagnosed nine years ago. One chest infection last year, treated by her GP. Full upper denture, stable. Eats the same meals as her husband, drinks from the bottle. No instrumental assessment so far.

Conditions: home visit, late morning, "on" period according to the patient. Alert. Seated at the table on an upright chair.

Oral examination: reduced facial expression, adequate lip seal. Tongue movement reduced in range and speed, symmetrical. Mild drooling late in the day reported by her husband. Weak voluntary cough. Quiet voice.

Trials

• Water, level 0, free sips from a glass: cough on the second sip, wet voice afterwards. Trial stopped.
• Water, level 0, small sip, chin slightly tucked: no cough over three sips, slow swallow onset.
• Level 2 drink, by spoon then glass: no warning signs over five sips.
• Apple purée, level 4: prolonged oral phase, some residue on the tongue, cleared by a second swallow.
• Flaked fish and soft vegetables, level 6: slow but effective chewing, no warning signs, some residue cleared by a second swallow.
• Soft bread and cheese, level 7: slow chewing, fatigue after a few mouthfuls, residue in the cheeks.
• Not tested: mixed textures (soup with pieces), because of the patient's fatigue.

Summary: oropharyngeal dysphagia related to Parkinson's disease, with an impaired oral phase (slow transit, residue) and delayed pharyngeal swallow onset on thin liquids. Warning signs on free sips of water, absent with level 2 drinks. The bedside assessment cannot exclude silent aspiration, especially given last year's chest infection.

Therapist's recommendations

• Level 2 drinks for now; level 0 water only in small sips, chin tucked, seated, outside periods of fatigue.
• Level 6 food recommended until review; avoid mixed textures combining liquid and solid pieces.
• Meals seated at the table, without distractions, during "on" periods when possible; smaller, more frequent meals if tired.
• Her husband reports to the doctor any repeated coughing at meals, fever or further weight loss.
• Suggestions to the neurologist: instrumental swallowing assessment, dietitian review for weight monitoring.

Care plan: dysphagia therapy (NGAP line "Rééducation des dysphagies"), two sessions a week. Goals: improve tongue propulsion, work on voluntary cough strength, make the chin tuck automatic, train her husband in the adaptations. Review in three months, or sooner if any warning sign appears.

Common mistakes

• Textures described in kitchen words ("mashed", "jelly water") instead of IDDSI levels: each setting reads them differently.
• A trial without conditions: without volume, utensil and posture, the trial cannot be repeated and the review compares nothing.
• "No aspiration" written after a bedside trial: write "no clinical sign of aspiration" instead, and state the limits.
• Recommendations buried in the summary: care staff must find them at a glance, in their own section.
• No fee code, or one that does not match the referral.
• A tool cited without its version, or a result read beyond what the tool allows.
• Nothing on what was not tested: an untested texture is not an approved texture.

Checklist before sending

• Referral, date, reason and fee code (NGAP line or INAMI code) stated
• History with chest infections, weight, current diet and previous assessments
• Assessment conditions (alertness, posture, time of day, "on" or "off" period if relevant)
• Each trial with IDDSI level, volume, utensil, posture and observed signs
• Trials not done and why
• Summary with phases affected and limits of the bedside assessment
• Recommendations in a separate section, in IDDSI levels
• Suggested investigations addressed to the doctor, not ordered
• Goals, number and type of sessions, review date
• Recipients chosen with the patient's agreement

Why Delta fits this assessment

During the assessment, Delta transcribes what is said, or you dictate your observations straight afterwards: it drafts the report in the structure and wording of your own reports, then keeps the memory of the follow-up so the review starts from there. Delta does not score tests, calculate any score or pick the fee code: those decisions stay yours. Data stays in Europe, in France, on infrastructure certified for health data, and no audio is kept. To find out more, read what Delta is.

Further reading

• Aphasia assessment report template
• All our clinical document templates

Sources

• Assurance Maladie, NGAP, version in force from 01/01/2026, title IV, chapter II, article 2 (French)
• INAMI, article 36 of the nomenclature (speech therapy), consolidated text in force from 1 August 2024 (French)
• IDDSI framework and descriptors (CC BY-SA 4.0) and patient handouts
• Lechien et al., validation of the French version of the EAT-10, European Archives of Oto-Rhino-Laryngology, 2019