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

Ed M Bice1, Nicole K Tomitz2, Steven J Baumrucker3

  • 1Clinical Consulting, IOPI Medical, Woodinville, WA.

American Journal of Speech-Language Pathology
|March 30, 2026
PubMed
Summary
This summary is machine-generated.

Speech-language pathologists (SLPs) often fail to fully document informed consent for diet modifications. This gap in documenting understanding, disclosure, treatment, alternatives, and choice risks patient autonomy and clinician liability.

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Area of Science:

  • Healthcare documentation practices
  • Patient autonomy and informed consent
  • Speech-language pathology interventions

Background:

  • Informed consent is a critical legal and ethical standard in healthcare.
  • Limited research exists on how speech-language pathologists (SLPs) document informed consent for diet modifications.
  • Diet modifications are common recommendations for individuals with dysphagia.

Purpose of the Study:

  • To investigate the documentation of the five core components of informed consent in SLP reports recommending diet modifications.
  • To identify gaps between ethical standards and current SLP documentation practices.
  • To compare documentation across different clinical settings and assessment types.

Main Methods:

  • Retrospective review of 201 clinical swallow evaluations, videofluoroscopic swallowing study (VFSS), and flexible endoscopic evaluations of swallowing reports.
  • Reports were sourced from medical records across acute and outpatient settings.
  • Two raters achieved consensus on the presence of five informed consent components: understanding, disclosure, treatment, alternatives, and choice.

Main Results:

  • SLPs documented an average of only two out of five informed consent components; no report included all five.
  • Documentation of "choice" was significantly higher in outpatient settings (p = .006).
  • Clinical swallow evaluations were less likely to include "understanding" (p = .02) and "choice" (p > .001) compared to instrumental assessments.

Conclusions:

  • A significant gap exists between ethical/legal informed consent standards and SLP documentation practices for diet modifications.
  • Incomplete documentation may jeopardize patient autonomy and increase professional liability risks.
  • Enhanced education, training, and protocol implementation are crucial for best practice and safeguarding patients and clinicians.