Revised 01/07Short Observation Patie nt Locatio n VIC Site of Analysis CAC Date of uati on Primary Cli nicia n Patient IDYYes,NNo,UU nable to determ in e/seeThi n LiquidNectar-ThickHon ey-ThickOral ResidueY / N / UY / N / UY / N / UVallecular ResidueY / N / UY / N / UY / N / UPyri Sinus ResidueY / N / UY / N / UY / N / UResidue in UESY / N / UY / N / UY / N / U.aryngeal PenetrationY / N / UY / N / UY / N / USilent PenetrationY / N / UY / N / UY / N / UAspirationY / N / UY / N / UY / N / USilent AspirationY / N / UY / N / UY / N / UAbnormal Initation DelayY / N / UY / N / UY / N / UPureeSolidCupTh Ne HoOral ResidueY / N / UY / N / UY / N / UVallecular ResidueY / N / UY / N / UY / N / UPyri Sinus ResidueY / N / UY / N / UY / N / UResidue in UESY / N / UY / N / UY / N / U.aryngeal PenetrationY / N / UY / N / UY / N / USilent PenetrationY / N / UY / N / UY / N / UAspirationY / N / UY / N / UY / N / USilent AspirationY / N / UY / N / UY / N / UAbnormal Initation DelayY / N / UY / N / UY / N / UComplete Observation Lateral Patient Location VICSite of Analysis CACDate of uationPrimary ClinicianPatient IDYYes,NNo,UUnable to determine/seeLateral ViewSwallowSwallowSwallowSwallowSwallowViscosityVolumeTime-Date GeneratorInterventionDroolingY / N / UY / N / UY / N / UY / N / UY / N / UPoor Bolus ationY / N / UY / N / UY / N / UY / N / UY / N / UBolus Preparation AbsentY / N / UY / N / UY / N / UY / N / UY / N / UBolus Preparation Prolonged 10sY / N / UY / N / UY / N / UY / N / UY / N / UMaterial under the TongueY / N / UY / N / UY / N / UY / N / UY / N / UVertical MasticationY / N / UY / N / UY / N / UY / N / UY / N / UIncomplete Tongue-Palate ContactY / N / UY / N / UY / N / UY / N / UY / N / UOral ResidueY / N / UY / N / UY / N / UY / N / UY / N / UTongue PumpingY / N / UY / N / UY / N / UY / N / UY / N / UTongue ThrustY / N / UY / N / UY / N / UY / N / UY / N / USerial Swallows 2 secondary swallowsY / N / UY / N / UY / N / UY / N / UY / N / UNasal RegurgitationY / N / UY / N / UY / N / UY / N / UY / N / UTremorY / N / UY / N / UY / N / UY / N / UY / N / UBOT Approximated EpiglottisY / N / UY / N / UY / N / UY / N / UY / N / UAbnormal Initiation DelayY / N / UY / N / UY / N / UY / N / UY / N / UAbnormal Pharyngeal Transit TimeY / N / UY / N / UY / N / UY / N / UY / N / UInadequate BOT to PPW contactY / N / UY / N / UY / N / UY / N / UY / N / UReduced Velar ElevationY / N / UY / N / UY / N / UY / N / UY / N / UReduced Hyoid DisplacementY / N / UY / N / UY / N / UY / N / UY / N / UReduced Laryngeal DisplacementY / N / UY / N / UY / N / UY / N / UY / N / UNo Epiglottic InversionY / N / UY / N / UY / N / UY / N / UY / N / UPartial Epiglottic InversionY / N / UY / N / UY / N / UY / N / UY / N / UProlonged Epiglottic Inversion 1sY / N / UY / N / UY / N / UY / N / UY / N / UC-shaped Epiglottic CurlY / N / UY / N / UY / N / UY / N / UY / N / UVallecular ResidueY / N / UY / N / UY / N / UY / N / UY / N / UPyri Sinus ResidueY / N / UY / N / UY / N / UY / N / UY / N / USecondary Swallowcued / volcued / volcued / volcued / volcued / volResidue clearedY / N / UY / N / UY / N / UY / N / UY / N / UPharyngeal Wall ResidueY / N / UY / N / UY / N / UY / N / UY / N / ULaryngeal Penetration BeforeY / N / UY / N / UY / N / UY / N / UY / N / ULaryngeal Penetration DuringY / N / UY / N / UY / N / UY / N / UY / N / ULaryngeal Penetration AfterY / N / UY / N / UY / N / UY / N / UY / N / USilent PenetrationY / N / UY / N / UY / N / UY / N / UY / N / UAspiration BeforeY / N / UY / N / UY / N / UY / N / UY / N / UAspiration DuringY / N / UY / N / UY / N / UY / N / UY / N / UAspiration AfterY / N / UY / N / UY / N / UY / N / UY / N / USilent AspirationY / N / UY / N / UY / N / UY / N / UY / N / UInadequate UES openingY / N / UY / N / UY / N / UY / N / UY / N / UResidue in UESY / N / UY / N / UY / N / UY / N / UY / N / URetrograde FlowY / N / UY / N / UY / N / UY / N / UY / N / UDiverticulumY / N / UY / N / UY / N / UY / N / UY / N / UCP ProtuberanceY / N / UY / N / UY / N / UY / N / UY / N / UOther Lateral ObservationsComplete Observation A-P View Patie nt Location VIC Site of An alysis CAC Date of uati on Primary Cli nicia n Patie nt IDL二Left unilateral,R二Right unilateral,B二Bilateral Y二Yes,NNo,U二Un able to determ in e/seeAP ViewViscosityVolumeTime-Date Gen eratorIn terve nti onOral ResidueL / R / BNCli nically Sig ni fica ntY / N / UVallecular ResidueL / R / BNCli nically Sig ni fica ntY / N / UPyri Si nus ResidueL / R / BNCli nically Sig ni fica ntY / N / UEntry into esophagusL / R / BOther AP Observatio nsEstimate of Severity Patient Location VIC Site of An alysis CAC Date of uati on Primary Cli nicia n Patient IDPen etrati on-Aspirati on Scale *1 - Co ntrast does n ot en ter the airwayThi n1 2 3 4 5 6 7 82 - Con trast en ters the airway,rema ins aboveNectar 1 2 3 4 5 6 7 8the vocal folds; there is no residueHon ey 1 2 3 4 5 6 7 83 - Con trast remai ns above the vocal folds,Puree 1 2 3 4 5 6 7 8visible residue remai nsSolid 1 2 3 4 5 6 7 84 - Con trast con tracts the vocal folds,no residue5 - Con trast con tacts the vocal folds,visible residue rema ins6 - Con trast passes glottis,no subglottic residue is visible7 - Con trast passes the glottis,visible subglottic residuerema ins despite the patie nts resp onse8 - Con strast passes the glottis,visible subglottic residuerema ins,there is no patie nt resp onse* used with permission of Rosenbek,J.C.,Robbins,J.,Roecker,E.B.,Coyle,J.L.,Wood,J.L.1996.A penetration-aspiration scale.Dysphagia,11,93-98.Copyright Springer-Verlag,New York Inc.1996.Overal Dysphagia SeverityWithin Normal LimitsMildModerateSevereRecommendationsPatie nt Location VIC Site of An alysis CAC Date of uati onPrimary Cli nicia n Patient ID1 for each primary recomme ndati on,2 for other appropriate recomme ndati onsDiet NPODiet PPOCon trol Bolus SizeCon trol Bolus Viscosity-LiquidsCon trol Bolus Viscosity-SolidsCon trol RateAlter Medicati on In takeChi n TuckEffortful SwallowFollow Solids w/ LiquidsGlottal Closure rcisesHead Tur n LeftHead Turn RightHead Tilt LeftHead Tilt RightJaw JutMasako Man euverMen delsoh n Man euverMultiple SwallowsRange of Moti on rcisesStren gthe ningSafe Swallow Tech ni queShakerThermal-Tactile Applicati onRefer to Otolary ngologyRefer to NeurologyRefer to GIRefer to Pul monaryRefer to De ntalOther referrals