Dysphagia Diet Audit Form
Use this form to audit dysphagia diet compliance, meal service quality, and swallowing safety observations for a specific resident or patient.
Audit Details
Facility / Location
*
Audit Date
*
-
Month
-
Day
Year
Date
Auditor Name
*
Auditor Role / Title
*
Meal / Service Type Audited
*
Breakfast
Lunch
Dinner
Snack
Supplement
Other
Patient/Resident and Diet Information
Patient/Resident Identifier
*
Prescribed Dysphagia Diet Level
*
Please Select
Regular
Easy to Chew
Minced & Moist
Soft & Bite-Sized
Pureed
Other
Prescribed Liquid Consistency
*
Please Select
Thin
Mildly Thick
Moderately Thick
Extremely Thick
Other
Dietary Notes / Instructions
Observed Meal Compliance
Observed Compliance Audit Grid
*
Rows
Compliant
Partially compliant
Non-compliant
Not observed
Food texture compliance
1
2
3
4
Liquid consistency compliance
5
6
7
8
Portion size accuracy
9
10
11
12
Presentation/appearance
13
14
15
16
Temperature at service
17
18
19
20
Safe feeding/positioning practices
21
22
23
24
Signage/labeling accuracy
25
26
27
28
Food texture compliance status
*
Compliant
Partially compliant
Non-compliant
Not observed
Liquid consistency compliance status
*
Compliant
Partially compliant
Non-compliant
Not observed
Safe feeding and positioning practices observed
*
Compliant
Partially compliant
Non-compliant
Not observed
Overall observed meal compliance
*
1
2
3
4
5
Observed meal comments / notes
Items needing follow-up
Food texture
Liquid consistency
Portion size
Presentation/appearance
Temperature at service
Feeding/positioning
Signage/labeling
Other
Staff Communication and Safety Review
Staff understanding of the prescribed diet
*
Clear and accurate
Partially accurate
Unclear
Not assessed
Correct meal delivered to the correct person
*
Yes
No
Unable to confirm
Swallowing safety concerns observed
*
No concerns observed
Coughing or choking observed
Pocketing or prolonged chewing observed
Signs of fatigue during eating
Other concern observed
Additional notes
Findings and Follow-Up
Issues Identified
*
Diet texture mismatch
Fluid consistency mismatch
Unsafe feeding practice observed
Meal not delivered as ordered
Documentation incomplete
Patient/resident declined meal
Other
Corrective Actions Needed
*
Responsible Department/Person
*
Follow-Up Status
*
Yes
No
In Progress
Complete
Follow-Up Date
-
Month
-
Day
Year
Date
Submit Audit
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