EDC Stroke Proforma - BMJ Open Quality
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Template for Stroke (HASU+SU) Discharge Summaries
to be used in conjunction with ICHT Electronic Discharge Communication (EDC) system
| |Copy and paste into separate relevant boxes of EDC |
|Patient name | |
|Hospital number | |
|Reason for Admission | |
|Main Condition (choose from ICD-coded diagnosis list below this |ICD code : |
|table, then add free text detailing specific final diagnosis, | |
|including laterality) |Full diagnosis: |
|Other diagnosis | |
|Other Past Medical History (other comorbidities) | |
| |From here on, copy and paste into ‘Treatment’ box of EDC |
|Clinical Narrative (Treatment/Operation) |Clinical Narrative: |
|Mode of admission, progress, management, and complications | |
| | |
| | |
| | |
| | |
| | |
|Social history |Social history: |
|Include e.g. driving, usual place of residence, PoC, family input,| |
|mobility | |
|Vascular Risk factors |Vascular Risk factors: |
|Select from: | |
|Previous stroke or TIA | |
|Atrial fibrillation New diagnosis Y/N | |
|Diabetes New diagnosis Y/N | |
|Hypertension | |
|Hypercholesterolaemia | |
|Ischaemic heart disease | |
|Smoker | |
|Alcohol excess | |
|Increased BMI | |
|Physical Examination |Physical Examination: |
|On admission |On admission: |
| | |
|On discharge |On discharge: |
| | |
|BP on discharge: |BP on discharge: |
|National Institutes of Health Stroke Scale (NIHSS) score |NIHSS: |
|On admission | |
|Pre-discharge |On admission: |
| |Pre-discharge: |
|Treatment and procedures– eg: |Treatment and procedures: |
|Thrombolysis | |
|Aspirin/clopidogrel | |
|Antibiotic course | |
| | |
|Thrombectomy | |
|NG tube | |
|PEG tube | |
|Catheterisation | |
|PICC line | |
| | |
|Trial participation | |
|Relevant Investigations and Results |Relevant Investigations and Results: |
|CT brain |CT brain |
|MRI brain |MRI brain |
|CTA |CTA |
|Carotid Dopplers |Carotid Dopplers |
|Echocardiogram |Echocardiogram |
|ECG |ECG |
|Telemetry |Telemetry |
|CXR |CXR |
|Bloods: (abnormal or relevant normal) |Bloods |
|Glucose Random/fasting |Glucose |
|Cholesterol Random/fasting |Cholesterol |
|Urine: (if positive) |Urine |
| | |
|Discussion from Neuroradiology meeting | |
|(where applicable; include date) | |
|Physical Ability |Physical Ability: |
|e.g. level of mobility, swallowing, continence | |
| | |
|Barthel score |Barthel score |
|Prior to admission |Prior to admission |
|Pre-discharge |Pre-discharge |
| | |
|Modified Rankin Scale score |Modified Rankin Scale score |
|Prior to admission |Prior to admission |
|Pre-discharge |Pre-discharge |
|Cognition If applicable: |Cognition: |
|Abbreviated mental test | |
|Montreal Cognitive Assessment (MoCA) score | |
|Psychological assessment |Psychological assessment: |
|Specify if mood screen score available and assessment tool. | |
|Relevant Legal Information |Relevant Legal Information: |
|(e.g. was an independent Mental Capacity Act Advocate required) | |
|Discharge Arrangements |Discharge Arrangements: |
|(please select from below, modify if required) | |
|Discharged to usual place of residence | |
|Discharged home, no services required | |
|Discharged home, package of care arranged | |
|Discharged to residential home | |
|Discharged to nursing home | |
|Transferred to local Acute Stroke Unit for ongoing management | |
|Transferred to ______ ward under ____ team | |
|Other | |
|Advice, recommendations and future plans |Advice, recommendations and future plans: |
| |Where appropriate, individualised advice has been given regarding stopping smoking, |
| |alcohol consumption, a healthy diet and exercise. |
| | |
|Specify if differing target BP advice |Targets: |
| |BP 130 /80 |
| |Hb1Ac % 6 – 8 |
| |Cholesterol: TC less than 4 and LDL less than 2 |
|Also include where applicable: | |
|If AF/PAF and anticoagulant not commenced: document reason why | |
|not, or plan for future consideration | |
|Any other recommendations to GP (eg monitoring renal function) | |
|Unresolved issues | |
|Driving |Driving: |
|Include unless diagnosis non-stroke, or not applicable for other |DVLA guidelines state that you are not allowed to drive a private vehicle for at least |
|established reason |four weeks after the onset of a transient ischaemic attack (TIA) or stroke. |
| |Imperial College Healthcare NHS Trust recommends seeking medical advice prior to returning|
| |to driving. Taxi drivers or holders of a special licence will require additional advice. |
|Flying |Flying: |
|Include unless diagnosis non-stroke, or not applicable for other |Imperial College Healthcare NHS Trust recommends that you do not fly for six weeks after |
|established reason |the onset of a TIA or stroke. |
|Patient’s expressed wishes or concerns: |Patient’s expressed wishes or concerns: |
|Include any expressed patient wishes or concerns regarding their | |
|management | |
|Actions and Outstanding Investigations |Actions and Outstanding Investigations: |
|Awaited investigations or results | |
| | |
|Next INR check: when, where and subsequent plan (if applicable) | |
| | |
|Community & Specialist Services (e.g. nursing, therapy, home care)| |
| | |
|Hospital follow-up plan | |
|The follow-up plan will be decided upon by the Consultant but, in | |
|general, will be 6-8 weeks from discharge for patients admitted |Follow up plan: |
|with a stroke or TIA. In general, patients repatriated from HASU | |
|to local stroke units will not be followed up in CXH Stroke | |
|Clinic, however exceptions will be determined by the Consultant. | |
ICD Code for Main Condition (As per Stroke Database)
|Infarction |
|Infarct - Middle cerebral artery (TMCAS or PMCAS) ischaemic stroke - G460 |
|Infarct - Anterior cerebral artery territory ischaemic stroke - G461 |
|Infarct - Posterior cerebral artery territory ischaemic stroke - G462 |
|Infarct - Brain stem stroke syndrome - G463 |
|Infarct - Cerebellar stroke syndrome - G464 |
|Infarct - Pure motor lacunar syndrome - G465 |
|Infarct - Pure sensory lacunar syndrome - G466 |
|Infarct - Other lacunar syndromes - G467 |
| |
|Bleed/haemorrhage |
|Subarachnoid haemorrhage - Sequelae of subarachnoid haemorrhage - I630 |
|Haemorrhage - Intracerebral haemorrhage in hemisphere, subcortical - I610 |
|Haemorrhage - Intracerebral haemorrhage in hemisphere, cortical - I611 |
|Haemorrhage - Intracerebral haemorrhage in hemisphere, unspecified - I612 |
|Haemorrhage - Intracerebral haemorrhage in brain stem - I613 |
|Haemorrhage - Intracerebral haemorrhage in cerebellum - I614 |
|Haemorrhage - Intracerebral haemorrhage, intraventricular - I615 |
|Haemorrhage - Intracerebral haemorrhage, multiple localized - I616 |
|Haemorrhage - Other intracerebral haemorrhage - I618 |
|Haemorrhage - Intracerebral haemorrhage, unspecified - I619 |
| |
|Vascular/infective |
|Dissection - Dissection of cerebral arteries, non-ruptured - I670 |
|Aneurysm - Cerebral aneurysm, non ruptured - I671 |
|Progressive vascular leukoencephalopathy - Progressive vascular leukoencephalopathy - I673 |
|Hypertensive encephalopathy - Hypertensive encephalopathy - I674 |
|Moyamoya disease - Moyamoya disease - I675 |
|Cerebral Venous/Sinus thrombosis - thrombosis of intracranial venous system - I676 |
|Vasculitis - Cerebral arteritis, not elsewhere classified - I677 |
|Viral encephalitis - Unspecified viral encephalitis - A86X |
|Unspecified viral encephalitis - Unspecified viral encephalitis - A86X |
| |
|Epilepsy/Seizure |
|Epilepsy - Locl-rel(foc)part)symp epilep/ epilptic syn simple part seiz - G401 |
|Epilepsy - Locl-rel(foc)part)symp epilep/epilptic syn complex part seiz - G402 |
|Epilepsy - Generalized idiopathic epilepsy and epileptic syndromes - G403 |
|Epilepsy - Other generalized epilepsy and epileptic syndromes - G404 |
|Epilepsy - Epilepsy, unspecified - G409 |
| |
|TIA |
|Transient cerebral ischaemic attacks - Vertebro-basilar artery syndrome - G450 |
|Transient cerebral ischaemic attacks - Carotid artery syndrome (hemispheric) - G451 |
|Transient cerebral ischaemic attacks - Multiple and bilateral precerebral artery syndromes - G452 |
|Transient cerebral ischaemic attacks - Amaurosis fugax - G453 |
|Transient cerebral ischaemic attacks - Transient global amnesia - G454 |
|Transient cerebral ischaemic attacks - Other transient cerebral ischaemic attacks and related synd - G458 |
|Transient cerebral ischaemic attacks - Transient cerebral ischaemic attack, unspecified - G459 |
| |
|Migraine |
|Migraine - Migraine without aura [common migraine] - G430 |
|Migraine - Migraine with aura [classical migraine] - G431 |
|Migraine - Status migrainosus - G432 |
|Migraine - Complicated migraine - G433 |
|Migraine - Other migraine - G438 |
|Migraine - Migraine, unspecified - G439 |
| |
|Neoplasm |
|Malignant neoplasm of, cerebral meninges - Malignant neoplasm of meninges - C700 |
|Malignant neoplasm of, cerebral meninges - Malignant neoplasm of brain - C715 |
|Secondary malignant neoplasm of brain & cerebral meninges - Secondary malignant neoplasm of other sites - C793 |
| |
|Disorders of vestibular function |
|Disorders of vestibular function - Meniere's disease - H810 |
|Disorders of vestibular function - Benign paroxysmal vertigo - H811 |
|Disorders of vestibular function - Vestibular neuronitis - H812 |
|Disorders of vestibular function - Other peripheral vertigo - H813 |
|Disorders of vestibular function - Vertigo of central origin - H814 |
|Disorders of vestibular function - Other disorders of vestibular function - H818 |
|Disorders of vestibular function - Disorder of vestibular fucntion, unspecified - H819 |
| |
|Delirium/Mental health |
|Delirium not induced by alcohol and other psychoactive subs - Delirium not superimposed on dementia, so described - F050 |
|Delirium not induced by alcohol and other psychoactive subs - Delirium superimposed on dementia - F051 |
|Delirium not induced by alcohol and other psychoactive subs - Other delirium - F058 |
|Delirium not induced by alcohol and other psychoactive subs - Delirium, unspecified - F059 |
|Oth mental disord brain damag and dysfunction/physical dis - Organic delisional [schizophrenia-like] disorder - F062 |
|Somatoform disorders - Other somatoform disorders - F458 |
|Somatoform disorders - Somatoform disorder, unspecified - F459 |
|Dissociative [conversion] disorders - Dissociative [conversion] disorders, unspecified - F449 |
| |
|Other |
|Syncope and collapse - Syncope and collapse - R55X |
|Facial nerve disorders - Bell's palsy - G510 |
|Parkinson's disease - Parkinson's disease - G20X |
|Intracranial injury - Concussion - S060 |
|Multiple sclerosis - Multiple sclerosis - G35X |
|Other disorders of pancreatic internal secretion - Drug-induced hypoglycaemia without coma - E160 |
|Other - Please Specify - |
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