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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