Form Coding Instructions

Instructions: Based on your assessment, please answer the following questions about the individual's swallowing. For all questions, consider chronological age expectations when rating the individual. Note: This scale should be used for individuals whose primary concern is risk for aspiration or swallowing safety due to oral pharyngeal dysphagia. Dietary levels should be judged only on swallow function, and any influence of poor dentition should be disregarded

Source: American Speech-Language-Hearing Association

99853-4 What modified diet is recommended for the individual to swallow solids safely?

Observation ID in Form

1

Fully-Specified Name

Component
Recommended modified solids diet
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Long Common Name

Recommended modified solids diet

Basic Attributes

Class
SURVEY.SLP
Type
Surveys
First Released
Version 2.72
Last Updated
Version 2.72 (ADD)
Order vs. Observation
Observation

Normative Answer List LL6208-4

AnswerCodeScoreAnswer ID
Regular (no modifications)LA33257-9
Soft & bite sizedLA33256-1
Minced & moistLA33255-3
PureedLA33254-6
LiquidizedLA33253-8
No solidsLA33252-0

Member of these Panels

LOINCLong Common Name
99852-6Functional Communication Measure - Swallowing panel [ASHA NOMS]

99854-2 What modified liquid is recommended for the individual to swallow safely?

Observation ID in Form

2

Fully-Specified Name

Component
Recommended modified liquids diet
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Long Common Name

Recommended modified liquids diet

Basic Attributes

Class
SURVEY.SLP
Type
Surveys
First Released
Version 2.72
Last Updated
Version 2.72 (ADD)
Order vs. Observation
Observation

Normative Answer List LL6212-6

AnswerCodeScoreAnswer ID
Thin liquids (no modifications)LA33267-8
Slightly thickLA33268-6
Mildly thickLA33269-4
Moderately thickLA33270-2
Extremely thickLA33271-0
No liquidsLA33272-8

Member of these Panels

LOINCLong Common Name
99852-6Functional Communication Measure - Swallowing panel [ASHA NOMS]

99855-9 What percentage of the individual's daily diet is delivered through non-oral means in order to maintain adequate nutrition and hydration?

Observation ID in Form

3

Fully-Specified Name

Component
Percentage of daily diet delivered through non-oral means
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Long Common Name

Percentage of daily diet delivered through non-oral means

Basic Attributes

Class
SURVEY.SLP
Type
Surveys
First Released
Version 2.72
Last Updated
Version 2.72 (ADD)
Order vs. Observation
Observation

Normative Answer List LL6213-4

AnswerCodeScoreAnswer ID
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value)LA137-2
<=25% of calorie intakeLA33274-4
26-49% of calorie intakeLA33275-1
50-75% of calorie intakeLA33276-9
>75% of calorie intakeLA33277-7

Member of these Panels

LOINCLong Common Name
99852-6Functional Communication Measure - Swallowing panel [ASHA NOMS]

99856-7 How often does the individual exhibit difficulties with oral containment or secretion management?

Observation ID in Form

4

Fully-Specified Name

Component
Frequency of difficulties with oral containment or secretion management
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Long Common Name

Frequency of difficulties with oral containment or secretion management

Basic Attributes

Class
SURVEY.SLP
Type
Surveys
First Released
Version 2.72
Last Updated
Version 2.72 (ADD)
Order vs. Observation
Observation

Normative Answer List LL6183-9

AnswerCodeScoreAnswer ID
0-25% of the time (rarely)LA33175-3
26-49% of the time (sometimes)LA33176-1
50-75% of the time (often)LA33177-9
76-90% of the time (most of the time)LA33178-7
91-100% of the time (always)LA33179-5

Member of these Panels

LOINCLong Common Name
99852-6Functional Communication Measure - Swallowing panel [ASHA NOMS]

99857-5 How often does the individual require supervision/assistance at meal time due to swallowing safety?

Observation ID in Form

5

Form Context

(e.g., risk of aspiration, pocketing)

Source: American Speech-Language-Hearing Association

Form Coding Instructions

If individual is NPO, rate supervision/assistance as 91-100% of the time

Source: American Speech-Language-Hearing Association

Fully-Specified Name

Component
Frequency of required supervision or assistance for swallowing safety
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Long Common Name

Frequency of required supervision or assistance for swallowing safety

Basic Attributes

Class
SURVEY.SLP
Type
Surveys
First Released
Version 2.72
Last Updated
Version 2.72 (ADD)
Order vs. Observation
Observation

Normative Answer List LL6183-9

AnswerCodeScoreAnswer ID
0-25% of the time (rarely)LA33175-3
26-49% of the time (sometimes)LA33176-1
50-75% of the time (often)LA33177-9
76-90% of the time (most of the time)LA33178-7
91-100% of the time (always)LA33179-5

Member of these Panels

LOINCLong Common Name
99852-6Functional Communication Measure - Swallowing panel [ASHA NOMS]

99858-3 Functional Communication Measure - Swallowing score [ASHA NOMS]

Fully-Specified Name

Component
Functional Communication Measure - Swallowing score
Property
Score
Time
Pt
System
^Patient
Scale
Qn
Method
ASHA NOMS

Basic Attributes

Class
SURVEY.SLP
Type
Surveys
First Released
Version 2.72
Last Updated
Version 2.72 (ADD)
Order vs. Observation
Observation

Member of these Panels

LOINCLong Common Name
99852-6Functional Communication Measure - Swallowing panel [ASHA NOMS]

Example Units

UnitSource
{score}Example UCUM Units