Version: PMM 12.12

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 table, then addfree text detailing specific final diagnosis, including laterality) / ICD code :
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)
Mode of admission, progress, management, and complications / Clinical Narrative:
Social history
Include e.g. driving, usual place of residence, PoC, family input, mobility / Social history:
Vascular Risk factors
Select from:
Previous stroke or TIA
Atrial fibrillationNew diagnosis Y/N
DiabetesNew diagnosis Y/N
Hypertension
Hypercholesterolaemia
Ischaemic heart disease
Smoker
Alcohol excess
Increased BMI / Vascular Risk factors:
Physical Examination
On admission
On discharge
BP on discharge: / Physical Examination:
On admission:
On discharge:
BP on discharge:
National Institutes of HealthStroke Scale (NIHSS) score
On admission
Pre-discharge / NIHSS:
On admission:
Pre-discharge:
Treatmentand procedures– eg:
Thrombolysis
Aspirin/clopidogrel
Antibiotic course
Thrombectomy
NG tube
PEG tube
Catheterisation
PICC line
Trial participation / Treatment and procedures:
Relevant Investigations and Results
CT brain
MRI brain
CTA
Carotid Dopplers
Echocardiogram
ECG
Telemetry
CXR
Bloods: (abnormal or relevant normal)
Glucose Random/fasting
Cholesterol Random/fasting
Urine: (if positive)
Discussion from Neuroradiology meeting
(where applicable; include date) / Relevant Investigations and Results:
CT brain
MRI brain
CTA
Carotid Dopplers
Echocardiogram
ECG
Telemetry
CXR
Bloods
Glucose
Cholesterol
Urine
Physical Ability
e.g. level of mobility, swallowing, continence
Barthel score
Prior to admission
Pre-discharge
Modified Rankin Scale score
Prior to admission
Pre-discharge / Physical Ability:
Barthel score
Prior to admission
Pre-discharge
Modified Rankin Scale score
Prior to admission
Pre-discharge
Cognition If applicable:
Abbreviated mental test
Montreal Cognitive Assessment (MoCA) score / Cognition:
Psychological assessment
Specify if mood screen score available and assessment tool. / Psychological assessment:
Relevant Legal Information
(e.g. was an independent Mental Capacity Act Advocate required) / Relevant Legal Information:
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 / Discharge Arrangements:
Advice, recommendations and future plans
Specify if differing target BP advice
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
/ Advice, recommendations and future plans:
Where appropriate, individualised advice has been given regarding stopping smoking, alcohol consumption, a healthy diet and exercise.
Targets:
BP 130 /80
Hb1Ac % 6 – 8
Cholesterol: TC less than 4 and LDL less than 2
Driving
Include unless diagnosis non-stroke, or not applicable for other established reason / Driving:
DVLA guidelines state that you are not allowed to drive a private vehicle for at least 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
Include unless diagnosis non-stroke, or not applicable for other established reason / Flying:
Imperial College Healthcare NHS Trust recommends that you do not fly for six weeks after the onset of a TIA or stroke.
Patient’s expressed wishes or concerns:
Include any expressed patient wishes or concerns regarding their management / Patient’s expressed wishes or concerns:
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 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. / Actions and Outstanding Investigations:
Follow up plan:

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 -