Acute Stroke Alert Note (ED/Inpatient)

Date/Time of Note: [date and time]
Time of First Assessment: [date and time]
Encounter Context: [ED arrival / inpatient event / transfer-in]
Author/Service: [author name, credentials, service]
History Sources: [patient / family / EMS / nursing / chart] (Note reliability and any limitations such as aphasia, encephalopathy, or sedation.)
Interpreter Used: [none / language and modality]

Stroke Alert Summary

• Activation trigger: [triggering symptom or finding]
• Presenting symptoms: [key neurologic deficits]
• Working syndrome/localization: [suspected vascular territory or undetermined]
• Thrombolysis candidacy: [yes / no / undetermined] — [brief rationale]
• EVT candidacy: [yes / no / pending vascular imaging] — [brief rationale]
• Immediate threats: [airway compromise / severe hypertension / hypoglycemia / seizure / none] (Include only if present.)

Critical Timepoints

(Use 24-hour time. Include date if crossing midnight. Include source in parentheses when non-obvious. If times conflict from different sources, document both and indicate which was used for decision-making.)

• Last Known Well (LKW): [date and time / unable to determine] (Source: [source]; if unable to determine, document attempts made.)
• Symptom onset or discovery: [date and time / not witnessed] (Source: [source])
• Hospital arrival (door time): [date and time] (ED encounters only.)
• Stroke alert activation: [date and time]
• First clinician exam/NIHSS: [date and time]
• NCCT start: [date and time]
• Vascular imaging start: [date and time] (If obtained.)
• CT perfusion/MRI start: [date and time] (If obtained.)
• Thrombolytic bolus: [date and time] (If given.)
• Neurointerventional activation: [date and time] (If EVT pursued.)
• [Inpatient] Last at baseline per nursing: [date and time]
• [Inpatient] Symptoms first noted: [date and time]
• [Transfer] Transfer request: [date and time]
• [Transfer] Accepting physician/facility: [name and facility]
• [Transfer] Door-out: [date and time]

Clinical History

[Chief concern]. [Onset pattern: sudden / stuttering / wake-up / resolved] with [symptom evolution and course]. Baseline neurologic function [pre-stroke mRS if known]. Associated features: [seizure activity / headache / fever / trauma / none]. Thrombolysis-relevant history: [anticoagulant or antiplatelet with last dose time], [bleeding history with dates], [recent surgery or procedures with dates], [pregnancy status if relevant]. Weight: [weight in kg] ([measured / stated]). (Keep concise; focus on factors affecting reperfusion eligibility.)

Neurologic Examination

• Mental status: [level of consciousness, orientation, attention]
• Language/dysarthria: [expression, comprehension, speech clarity]
• Cranial nerves: [gaze, visual fields, facial symmetry]
• Motor: [strength with attention to drift, distribution]
• Sensory: [intact / reduced with distribution]
• Coordination: [finger-nose, heel-shin if tested]
• Neglect/inattention: [present / absent]
• Exam limitations: [sedation / intubation / language barrier / agitation / none]

NIHSS: [total score] at [time]. [Limitations affecting scoring, if any.] (Itemized components may be attached separately. If not performed, state reason.)

Objective Data

• Vital signs at decision time: BP [value], HR [value], RR [value], SpO2 [value] on [room air / supplemental O2], Temp [value]
• Point-of-care glucose: [value] at [time]
• Weight: [value in kg] ([measured / stated / estimated])
• Pertinent labs: [platelets, INR, aPTT, hemoglobin, creatinine, troponin as relevant] (Include only if influenced timing or eligibility.)
• ECG rhythm: [sinus / atrial fibrillation / other] (If available.)
• Labs awaited prior to thrombolysis: [yes with list / no] — [rationale if not awaited]

Imaging Review

• NCCT head: [time performed]; Hemorrhage [yes / no]; Early ischemic changes [present / absent]; ASPECTS [score] (Scored by [clinician / radiology].)
• Vascular imaging: [obtained / not obtained]; LVO [present / absent]; Location [site if present]; Extracranial findings [stenosis / dissection / none]
• Perfusion/MRI: [core/penumbra summary or DWI-FLAIR mismatch] (If obtained; include EVT selection criteria if extended window.)
• Critical results communication: [time] by [who] to [recipient]; [impact on management]

Assessment

[Primary working diagnosis: ischemic stroke / hemorrhagic stroke / TIA / stroke mimic]. Suspected territory: [vascular territory and mechanism]. Key differentials: [seizure/postictal / hypoglycemia / migraine / functional / toxic-metabolic]. [Synthesis linking deficits to imaging findings.]

Reperfusion Decision

IV Thrombolysis

• Considered: [yes / no]
• If given: [alteplase / tenecteplase]; Dosing weight [kg]; Bolus/infusion start [time]; BP management [agents given, if any]; Delays [none / explanation]
• If not given, primary reason: [outside time window / hemorrhage on imaging / rapidly improving / anticoagulation contraindication / bleeding risk / patient or surrogate refusal / comfort-focused goals / other] — [supporting details; include LKW-to-decision calculation if time-based]
• Consent: [patient with capacity / surrogate consent / emergent implied consent]; Participants [names and relationship]; [Summary of risk-benefit discussion]; Interpreter [used / not needed]. (If implied consent, document rationale.)

Mechanical Thrombectomy (EVT)

(Include only if EVT considered or LVO present.)

• Status: [considered / activated / not indicated]
• LVO: [location] on [CTA / MRA]
• Severity: NIHSS [score]; Selection criteria if extended window: [core/penumbra or clinical-imaging mismatch]
• Neurointerventionalist: [name] contacted at [time]; Decision [proceed / not proceed] — [rationale]
• Transfer: Accepting facility [name]; Accepting physician [name]; Transport [ground / air] (If applicable.)

Immediate Management Plan

• Airway/oxygenation: [plan and O2 target]
• Blood pressure: Target [range]; Management [agents]; Post-thrombolytic protocol [yes / no / not applicable]
• Glucose: Target [range]; Management [plan]
• Antithrombotics: [agent and timing]; If post-thrombolytic: hold 24h pending repeat imaging [yes / no]
• DVT prophylaxis: [mechanical / pharmacologic with timing]
• NPO/swallow: NPO pending swallow evaluation [yes / no]; [Swallow screen or SLP consult plan]
• Monitoring: [ICU / stepdown / stroke unit]; Neuro checks [frequency]

Disposition and Handoff

• Final disposition: [ICU / stroke unit / floor / transfer / angiography suite]
• Neurologic status at handoff: [brief exam summary or NIHSS trend with time]
• Outstanding studies: [pending imaging / labs / repeat imaging timing]
• Monitoring pathway: [post-thrombolytic protocol / standard stroke monitoring]
• Handoff to: [role and name] at [time]
• Family communication: [completed / pending]; [Contact and key points discussed]
• [Transfer] Summary: LKW [time]; NIHSS [score]; Imaging [key findings]; Treatment times [list]; Thrombolysis contraindication [if not given]; Current drips/medications [list]

(When information is unknown, use explicit labels: "Unknown," "Unable to determine," or "Not witnessed." Document attempts to obtain missing information. Do not infer LKW; record reported time and source. Use 24-hour time throughout. Omit inapplicable sections except thrombolysis decision, which requires explicit documentation regardless of whether treatment was given.)