Informed Consent in Speech-Language Pathology Documentation When Recommending Diet Changes

Informed consent is a legal and ethical requirement in health care, yet limited research has examined how speech-language pathologists (SLPs) document the process when recommending diet modifications. The study investigated the presence of the five components of informed consent in SLP documentation.

A retrospective review was conducted on 201 clinical swallow evaluations, videofluoroscopic swallowing study (VFSS), and flexible endoscopic evaluations of swallowing reports. Reports were selected from medical records from two health care companies across acute and outpatient settings. Two raters reached consensus on the presence of the five core components of informed consent: understanding, disclosure, treatment, alternatives, and choice.

On average, SLPs documented only two of the five components, and no report contained all five. Documentation of "choice" was significantly higher in outpatient settings compared to acute care (p = .006). Clinical swallowing evaluations were less likely to include "understanding" (p = .02) and "choice" (p > .001) compared to instrumental assessments, such as VFSS and flexible endoscopic evaluations of swallowing.

The findings reveal a gap between ethical and legal standards and current documentation practices when recommending diet modifications. Incomplete documentation may compromise personal autonomy and increase the risk of professional liability. Enhanced education, targeted training, and systematic implementation of informed consent protocols are essential to promote best practice and safeguard both people with dysphagia and clinicians.