EMS Suspected Stroke/TIA Activation Note

Patient identifiers: [Full name / Unknown identity] (If unknown, briefly explain and include any temporary ID or descriptors)

DOB/Age: [YYYY-MM-DD / Age / Unknown]

Unit/Crew ID: [Unit number and crew identifiers]

Level of Care: [BLS / ALS]

Incident Type: [911 response / interfacility transfer / standby]

Location Type: [Private residence / SNF / Clinic / Public place / Other]

Symptoms witnessed: [Yes / No / Unknown] (If yes, note by whom; if no or unknown, briefly state why)

Stroke Activation Summary

(Use concise labeled lines for rapid read-out. For any stroke-critical element that cannot be determined, use explicit states: Unknown / Unable to determine / Not assessed, and briefly document why.)

Primary suspected syndrome: [Stroke / TIA / Stroke mimic possible] (Do not specify stroke subtype prehospital)

Key deficits observed: [Brief list of deficits with laterality, e.g., aphasia, R facial droop, L arm weakness, gaze deviation]

Last Known Well (LKW): [YYYY-MM-DD HH:MM] | Source: [Patient / Witness / Staff / Record / Device] (If unable to determine, state why)

Symptom discovery: [YYYY-MM-DD HH:MM] | Source: [Patient / Witness / Staff / Record]

POC glucose: [Value] mg/dL at [HH:MM] via [fingerstick / venous] (If not obtained, state reason)

Stroke screen: [Tool name] at [HH:MM] — Result: [Positive / Negative / Inconclusive] — Components: [List each component as + or − with laterality]

LVO severity screen: [Not performed / Tool name] at [HH:MM] — Score: [Numeric] — Components: [Findings] (If not performed, state reason)

Anticoagulant/antithrombotic status: [Yes / No / Unknown] (If yes: [Drug name]; Last dose [YYYY-MM-DD HH:MM / Unknown])

BP trend (snapshot): First [SBP/DBP] at [HH:MM]; Highest [SBP/DBP] at [HH:MM]; Last [SBP/DBP] at [HH:MM]

Destination facility: [Facility name] — Stroke designation: [Acute Stroke Ready / Primary / Thrombectomy-capable / Comprehensive / Unknown]

Pre-arrival notification: [Yes / No] (If yes: Notified at [HH:MM]; ETA [HH:MM]; Contact [Role/department]; Method [radio / phone / app]. If no, state reason)

Timeline

(List events in chronological order using 24-hour time. Include date when events cross midnight.)

• [YYYY-MM-DD HH:MM] Dispatch/unit notified
• [YYYY-MM-DD HH:MM] Scene arrival
• [YYYY-MM-DD HH:MM] Patient contact
• [YYYY-MM-DD HH:MM] Stroke screen completed
• [YYYY-MM-DD HH:MM] Glucose obtained
• [YYYY-MM-DD HH:MM] Pre-arrival notification initiated
• [YYYY-MM-DD HH:MM] Scene departure
• [YYYY-MM-DD HH:MM] Neurologic change during transport: [Improved / Worsened / New deficit] — [Brief description] (Include only if applicable)
• [YYYY-MM-DD HH:MM] Destination arrival

Last Known Well Determination

LKW date/time: [YYYY-MM-DD HH:MM / Unable to determine] (Last time patient was at neurologic baseline without current stroke symptoms)

LKW source and reliability: Source: [Patient / Witness / Facility staff / Medical record / Device timestamp]; Reliability: [High / Moderate / Low] — [Brief justification]

Symptom discovery: [YYYY-MM-DD HH:MM]; Discovered by: [Name/role/relationship]

Wake-up stroke: [Yes / No / N/A] (If yes, LKW equals sleep onset at baseline: [YYYY-MM-DD HH:MM])

Multiple reported times: [List each reported time with source] — Time used for activation: [HH:MM] — Rationale: [Why this time was selected] (Include only if conflicting times reported)

(Do not infer LKW from dispatch time, arrival time, or patient appearance. Only record times obtained from a person or record. Label estimates as "approx.")

Focused Stroke History

Chief complaint: [Quoted patient/witness words or succinct summary] (If not obtainable, state reason)

Symptom narrative: [Sudden vs gradual onset; Fluctuating vs persistent; Improving/resolved vs worsening; Brief time course]

Associated symptoms: [Headache / Nausea-vomiting / Seizure-like activity / Trauma-fall / Vision changes / Other / Denied] (List positives and pertinent negatives)

Baseline functional status: [Independent / Needs assistance / Bedbound / Unknown] — [Pre-existing neurologic deficits if any]

Pertinent comorbidities: [Atrial fibrillation / Prior stroke or TIA / Hypertension / Diabetes / Recent surgery / Recent bleeding / Other] (Include only if obtained)

Anticoagulants/antithrombotics: [Yes / No / Unknown] (If yes: [Drug name]; Last dose [YYYY-MM-DD HH:MM / Unknown])

Recent bleeding risk factors: [Yes / No / Unknown] (If yes, specify)

History limitations: [Aphasia / Altered mental status / No collateral available / Language barrier / None] — [Attempts made to obtain collateral]

Neurologic Examination

Mental status: [Alertness; Orientation; Ability to follow commands; Aphasia vs dysarthria if applicable]

Cranial nerves: [Facial symmetry; Gaze deviation; Pupils; Visual fields; Neglect/inattention] (Document abnormal findings; state "No focal abnormalities" if none)

Motor: [Arm drift; Leg drift; Weakness location and severity; Sensation changes; Ataxia]

Stroke screen: [Tool name] at [HH:MM]

• [Component 1]: [Positive / Negative / Not assessed]
• [Component 2]: [Positive / Negative / Not assessed]
• [Component 3]: [Positive / Negative / Not assessed]

(Add or remove components to match tool used. If stroke screen not performed, state "Not performed" with reason.)

Severity/LVO scale: [Not performed / Tool name] at [HH:MM] — Score: [Numeric]

• [Component]: [Finding]
• [Component]: [Finding]

(Include only if performed; if not performed, state reason)

Vitals and Glucose

(At minimum capture initial, worst, and pre-arrival values. Include rhythm if monitored.)

• Initial: [HH:MM] — BP [SBP/DBP] mmHg; HR [bpm]; RR [breaths/min]; SpO2 [%] on [room air / O2 L/min]; Rhythm [interpretation]
• Worst: [HH:MM] — [Parameter]: [Value] — Context: [Brief note]
• Pre-arrival: [HH:MM] — BP [SBP/DBP] mmHg; HR [bpm]; RR [breaths/min]; SpO2 [%]; Rhythm [interpretation]

Hypertension management: [Treated / Not treated / Not indicated] (If treated: [Medication] [Dose] [Route] at [HH:MM]; Response: [Effect]. If not treated, state rationale)

POC glucose: [Value] mg/dL at [HH:MM] via [fingerstick / venous] (If hypoglycemic: Treatment [Agent/dose/route/time]; Response: [Effect]. If not obtained, state reason)

Interventions

• Airway/oxygen: [Airway status; O2 route/flow; Suctioning; Positioning; Aspiration precautions] — Times and response
• IV/IO access: [Site; Gauge; Attempts; Fluids and rate] — Times
• Cardiac monitoring/12-lead: [Monitoring start time; Rhythm; 12-lead findings if obtained]
• Seizure management: [Medication; Dose; Route; Time; Response] (Include only if applicable)
• Hypoglycemia treatment: [Agent; Dose; Route; Time; Response] (Include only if applicable)
• Medical control consultation: [Time]; Contacted [Role]; Orders received: [Summary] (Include only if applicable)
• Interventions considered but not performed: [Intervention] — Rationale: [Reason] (Include only if applicable)

Destination and Pre-Arrival Notification

Destination facility: [Facility name]; Stroke designation: [Acute Stroke Ready / Primary / Thrombectomy-capable / Comprehensive / Unknown]

Transport mode: [Ground / Air]

Destination decision: [Closest appropriate / Bypass] — Rationale: [LKW window; Severity/LVO screen result; Transport time; Patient stability; Protocol reference]

Pre-arrival notification: [Performed / Not performed]

Time: [HH:MM]; Contact: [Role/department]; Method: [radio / phone / app]

Content communicated: [Suspected stroke/TIA; LKW; Stroke screen findings; Glucose; Anticoagulant status; BP extremes; ETA; Clinical instability if any]

(If not performed, state reason)

Handoff

Arrival time: [YYYY-MM-DD HH:MM]

Handoff time: [YYYY-MM-DD HH:MM]

Care transferred to: [Role/title]

Neurologic status at handoff: [Improved / Worsened / Unchanged] compared to initial — Key deficits: [Brief restatement]

Interval changes during transport: [Description / None]

Final vital signs: [HH:MM] — BP [SBP/DBP] mmHg; HR [bpm]; RR [breaths/min]; SpO2 [%]

(Do not leave stroke-critical elements blank. If any element is unknown, state Unknown / Unable to determine / Not assessed with a brief reason.)