Understanding STROKE Text: A Quick Guide for Clinicians

STROKE Text Templates: Ready-to-Use Examples for Documentation

Purpose

Provide concise, standardized documentation templates for stroke-related encounters to improve clarity, handoffs, billing, and quality reporting.

When to use

• ED assessments of suspected stroke
• Inpatient daily notes and progress checks
• Discharge summaries and caregiver instructions
• Telestroke consults and transfer requests

Core sections (use in every template)

• Chief complaint / Reason for visit
• Time last known well (LKW)
• Onset description (witnessed/unwitnessed; progressive/sudden)
• NIH Stroke Scale (NIHSS) with individual item scores
• Vital signs / glucose
• Neuro exam (focused)
• CT/CTA/MRI results and time obtained
• Eligibility for thrombolysis or thrombectomy (include contraindications)
• Treatment given (medication, dose, time)
• Disposition / plan (admit location, consults, transfer)
• Secondary prevention and discharge meds
• Follow-up and caregiver instructions

Ready-to-use templates

1) ED initial stroke evaluation (acute)

Chief complaint: Acute [hemiparesis/aphasia/vision loss/etc.] — LKW: [time].
Onset: [sudden/witnessed/unwitnessed]; last seen normal: [time].
NIHSS: total score.
Vitals: HR [ ], BP [ ], RR [ ], SpO2 [ ], Glu [ ].
Focused neuro: [brief findings].
CT head (non-contrast) at [time]: [normal/ischemic hemorrhage]. CTA at [time]: [LVO yes/no].
Labs: CBC, BMP, coag, troponin, pregnancy, Tox — results pending/available.
tPA eligibility: [eligible/not eligible] — if given: tPA alteplase [mg], bolus/infusion start [time].
Thrombectomy candidacy: [yes/no]; interventional consult placed at [time].
Plan: Admit to [stroke unit/ICU]; repeat neuro checks q15min x4 then q30min x4; consult PT/OT/Speech; stat dysphagia screen prior to PO.

2) Telestroke consultation note

Referring facility: [hospital]. LKW: [time]. Neuro deficits: [summary]. Imaging: CT/CTA attached — findings: [LVO location/ASPECTS]. tPA: [given/considered/not given; dose/time]. Recommendation: [transfer for thrombectomy/observe at local with plan X/administration of tPA]. Transportation: [arrange transfer via stroke protocol].

3) Inpatient daily progress (post-acute)

Date/time: [ ]. Status: Post-stroke day [ ]. Neuro: NIHSS [ ], changes since prior: [ ]. Meds: antiplatelet/anticoagulation, statin, BP plan. Rehab: PT/OT/Speech progress and goals. Complications: DVT prophylaxis, UTI, aspiration risk. Plan: Continue stroke unit care, escalate if decline, arrange discharge planning meeting.

4) Discharge summary (stroke)

Admission dx: Ischemic stroke due to [etiology]. Hospital course: summary of acute treatment (tPA/thrombectomy), complications, imaging. At discharge: neuro status (NIHSS or mRS), meds started (ASA 81 mg daily, statin X mg, BP meds), risk factor modifications, swallow status, mobility. Follow-up: neurology clinic in 1–2 weeks, primary care, cardiology if indicated. Red flags: return for new weakness, worsening speech, severe headache, bleeding signs.

5) Family/caregiver instruction sheet (plain language)

What happened: [brief stroke explanation]. Medications to take: [list with doses and purpose]. Activity: safe mobility recommendations, fall precautions. Diet: dysphagia guidance if applicable. When to call 911: sudden worsening, new weakness, severe headache, trouble breathing. Appointments: [dates/times]. Contact: stroke coordinator/clinic phone.

Quick language templates (copy-paste snippets)

• “LKW: [HH:MM]. Onset: sudden. NIHSS: [score]. Non-contrast CT 0% hemorrhage at [time]. tPA administered: alteplase [mg], bolus at [time], infusion started at [time].”
• “CTA: occlusion at [M1/M2/ICA]; ASPECTS [score]; recommend transfer for thrombectomy.”
• “Discharge meds: Aspirin 81 mg PO daily, Atorvastatin 80 mg nightly, Lisinopril 10 mg PO daily.”

Implementation tips

• Use standardized fields in EHR templates for LKW, NIHSS, and imaging times to support treatment windows and quality metrics.
• Keep caregiver sheet at <1 page, use large font, bullets, and bold critical actions (e.g., "Call 911").
• Include timestamps for all stroke-time-sensitive actions (door, CT, tPA, groin puncture).

One-sentence checklist

Ensure LKW, NIHSS, CT timing, tPA/thrombectomy decisions, treatment times, and disposition are documented clearly and timestamped.