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S
peech
P
athology
A
ustralia
Work– l i f e balance : preserv i ng your soul
Appendix A.Weekend speech pathology service referral
continued
Outcome of most recent speech pathology contact:
Request weekend service intervention:
Initial assessment – swallowing
Initial assessment – communication
Review current diet
Educate patient/family re swallowing management
Direct swallowing therapy (please specify)
Communication therapy (please specify)
Check patient’s medical chart/check with nursing staff
Other (please specify)
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Frequency of service requested:
Saturday
Sunday
Estimated priority ranking (by patient’s usual SP):
COMPLETED BY SUPERVISING SPEECH PATHOLOGIST:
Patient prioritisation (before new referrals are received): _ ___________________________________________
SATURDAY
Weekend service provided:
Initial dysphagia assessment
Initial communication assessment
Swallowing review
Swallowing therapy
Communication therapy
Education regarding swallowing management
Discussion with nursing or medical team/checking of
patient’s notes
Other (please specify)
_ ___________________________________________________
_ ___________________________________________________
The outcome of this service was:
Diet continued: no change to patient’s current management
plan
Patient commenced oral feeding:
Enteral feeding was commenced
Patient was not admitted to hospital over the weekend due
to intervention
Diet downgraded:
Diet: ________________________________________________
Diet upgraded:
Diet: ________________________________________________
SUNDAY
Weekend service provided:
Initial dysphagia assessment
Initial communication assessment
Swallowing review
Swallowing therapy
Communication therapy
Education regarding swallowing management
Discussion with nursing or medical team/checking of
patients notes
Other (please specify)
____________________________________________________
____________________________________________________
The outcome of this service was:
Diet continued: no change to patient’s current management
plan
Patient commenced oral feeding: Diet:
Enteral feeding was commenced
Patient was not admitted to hospital over the weekend due
to intervention
Diet downgraded:
Diet upgraded:
Patient unable to be seen due to:
____________________________________________________