Lothian Stroke Clinical Audit System



Stroke Care Audit Form - Inpatients

| |Next of kin: ___________________________________________ |

| |NOK phone: ______________ |Relationship: _______________ |

| |GP Initials: ___________ |GP Surname: _____________________ |

| |GP Postcode: _________ |GP Phone: _____________________ |

|Date of assessment : ____/____/____ | Time: ____:____ |Responsible consultant: _____________ |

|Seen as : _____________ | |Unit : _____________ |

|If Admitted, Date : ____/____/____ | Time: ____:____ |Admitted from1 : _____________ |

| Discharge Date : ____/____/____ | |Discharged to2 : _____________ |

|Cerebral3 : Stroke [__] | Transient ischaemic attack : [__] |Sub-arachnoid : [__] |

|Eye3: Retinal artery occlusion [__] | Transient monocular blindness: [__] | haemorrhage |

|Other: Possible cerebrovascular4 [__] | Details: | |

| Definite non-cerebrovascular [__] | Details: | |

|End data collection (please circle reason) |Deceased / Untraceable / Refused |Date : ____/____/____ |

|Date of first symptoms : ____/____/____ |Can the patient lift both arms off the bed? [__] |

|Was patient independent in ADL5 before event? [__] |Able to walk without help from other person? [__] |

|Was patient living alone at the time of event? [__] |Current AF confirmed on ECG? [__] |

|Can the patient talk6? [__] |On Aspirin at onset? [__] |

|Are they oriented in time, place and person? [__] |On Warfarin at onset? [__] |

|Swallow screening recorded ? [__] |Date of first screening : ____/____/____ |

|Was the patient managed in an acute [__] |Entry date: ___/___/___ |Unit : _____ |

|Stroke Unit ? |Exit date: ___/___/___ |Consultant: _______________ |

|Was the patient managed in a rehab [__] |Entry date: ___/___/___ |Unit : _____ |

|Stroke Unit ? |Exit date: ___/___/___ |Consultant: _______________ |

|Was the patient managed in a normal [__] |Entry date: ___/___/___ |Unit : _____ |

|Rehab unit ? |Exit date: ___/___/___ |Consultant: _______________ |

| | |

|Whether Aspirin given in hospital [__] |Date Aspirin started: ___/___/___ |

|Final Discharge from hospital on Aspirin [__] |MDT meeting(s) held ? ___ Date : |____/____/____ |

| " " on Clopidogrel (Plavix) [__] |Please record all dates Date : |____/____/____ |

| " " on Dipyridamole (Persantin) [__] | Date : |____/____/____ |

| " " on Warfarin [__] | Date : |____/____/____ |

| " " on a Statin [__] | Date : |____/____/____ |

|CT done ? [__] Date : ____/____/____ |Evidence of new haemorrhage on scan ? [__] |

|MRI done ? [__] Date : ____/____/____ | |

|Post-mortem performed [__] |Evidence of new haemorrhage on PM ? [__] |

|Final Syndrome Classification |LACS / PACS / POCS / |

|(use clinical & imaging data – please circle) |TACS / Uncertain / Eye7 |

|ICD 10 final diagnosis8 : _________________________________________ |

|Swallow screening recorded ? [__] |Date of first screening : ____/____/____ |

| Result ? (please circle): |Safe / Unsafe / Not recorded |

|Put Nil By Mouth (NBM) ? [__] |Date first recorded : ____/____/____ |

|Parenteral fluids (IV or SC) ? [__] |Date started : ____/____/____ |

|Enteral tube feeding (via NG or PEG) ? [__] |Date started : ____/____/____ |

|Seen by Speech & Language Therapist ? [__] |Date of first assessment : ____/____/____ |

|Feeding Recommendation ? (please circle): | |

|No advice re swallowing / Normal diet / |Swallowing regime / NBM / Not recorded |

| | |

|Any comment reflecting (baseline) nutritional status recorded within first two days of admission ? [__] |

|Baseline nutritional screening completed ? [__] |Date of first screening : ____/____/____ |

|Seen by dietitian ? [__] |Date of first assessment : ____/____/____ |

Notes :

Swallow screening result

Safe = patient judged able to take food and fluids orally.

Unsafe = patient judged not to be able to take food and fluids orally.

Parenteral fluids, enteral feeding and seen by Speech & Language Therapist (SLT)

Record use of parenteral fluids, enteral feeding and seen by SLT whatever the result of the swallow screen.

Seen by SLT

Answer Yes if seen for any reason. Thus if the SLT only refers to language or speech but does not mention swallowing ability record Yes, seen. As well as No, not seen, you can also record B for “no, But” if the patient is recorded as unconscious (Glasgow Coma Scale < 9) or as having respiratory complications e.g requiring regular suction / not clearing own secretions.

Feeding recommendation

If SLT only sees patient regarding speech / language and recommendations in that area are recorded but does not comment on swallowing then put recommendation ‘No advice re swallowing’.

Swallowing regime should be used if advice given on diet/fluid modification and/or advice on postures or methods of feeding or swallowing strategies.

Baseline nutritional status

Y for Yes = nutritional status assessed and recorded in notes. Status need not be assessed by any formal method, we accept any statement which reflects nutritional status including: thin, obese, cachectic or normal build.

N for No = no nutritional status assessment in medical or multidisciplinary notes.

Baseline nutritional screen completed

This refers to completion of a formal screening tool.

Seen by dietitian

Answer Yes if recorded as seen for any reason. Please use B for “no, But” if the patient has not been seen by dietitian but is clearly recorded as being for no active treatment or it is recorded that the patient has no nutritional problem (i.e. a normal screen).

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Final diagnosis and status

Address label

Chi No. Sex

Unit No.

Name Title

Address

Dob

Postcode

Telephone

Initial

assessment

Final

Classification

Inpatient

management

Swallowing /

feeding

Swallow screening recorded

Y for Yes = screening of swallowing completed and recorded in notes. The screen should follow the SIGN 20 recommendation: checks on conscious level, presence of laryngeal abnormality (e.g. voice quality, cough), respiratory status and a water swallow test. Therefore if patient is placed NBM due to a low conscious level (Glasgow coma scale less or equal to 9) record Yes.

N for No = no swallow screen recorded in medical or multidisciplinary notes.

Address label

Chi No. Sex

Unit No.

Name Title

Address

Dob

Postcode

Telephone

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