Stroke Alert Note

Note Title: Stroke Alert Note

Encounter Context: [ED / Inpatient stroke alert] | [Direct arrival / Interfacility transfer] | [In-person neurology / Telestroke]

Author/Team: [Documenting clinician role and name] | [Other team members present: neurology, neurointerventionalist, ED, pharmacy, nursing, radiology]

Alert Activation Time: [Date (YYYY-MM-DD)] [Time (HH:MM)]

Documentation Time: [Date (YYYY-MM-DD)] [Time (HH:MM)] (Only include if different from activation time.)

Pre-stroke Baseline: [Functional status, pre-stroke mRS if known, pre-existing neurologic deficits] (Clearly distinguish baseline deficits from new findings.)

At-a-Glance Summary

(Provide a brief high-yield summary, 6–8 lines maximum. If stroke alert was canceled as a false alarm, state "Stroke alert canceled" with the reason and limit to 1–2 lines.)

• Working syndrome: [Suspected ischemic stroke / Intracerebral hemorrhage / TIA / Mimic] (State uncertainty if present.)
• Last Known Well (LKW): [Date (YYYY-MM-DD)] [Time (HH:MM)] | Source: [Patient / Witness / EMS / Records] | Certainty: [High / Moderate / Low] (If unknown, state "Unknown/Unable to determine" with one-line explanation.)
• NIHSS: [Total score] at [Date (YYYY-MM-DD)] [Time (HH:MM)] by [Examiner]
• Imaging headline: NCCT [hemorrhage present / no hemorrhage]; CTA [LVO present (location/side) / no LVO / not obtained]
• Thrombolysis: [Given / Not given] — [One-line reason]
• Thrombectomy: [Pursued / Not pursued] — [One-line reason]
• Disposition: [ICU / Stroke unit / IR suite / Transfer to thrombectomy center / Floor / Discharge]

Key Timeline

(Use 24-hour format throughout. Include only events that occurred; do not back-calculate times unless explicitly labeled as computed. If LKW is unknown or conflicting across sources, list source-specific times and specify which is operative LKW with rationale.)

• Last Known Well: [Date] [Time] | Source: [Source] | Notes: [Certainty level or "Unknown/Unable to determine" with explanation]
• Symptom onset: [Date] [Time] (Include only if different from LKW; label if computed/estimated.)
• Time discovered abnormal: [Date] [Time] | Finder: [Witness/setting] (Include for unwitnessed/wake-up strokes.)
• Arrival/Recognition: [Date] [Time] | [ED arrival / In-hospital recognition] | [Mode/location]
• Stroke alert activation: [Date] [Time]
• Initial clinician evaluation: [Date] [Time] | [Clinician role/name]
• NIHSS performed: [Date] [Time] | Examiner: [Name/role]
• POC glucose: [Date] [Time] | Result: [Value with units]
• NCCT start: [Date] [Time]
• NCCT interpreted: [Date] [Time] | Interpreter: [Name] | [Preliminary / Final]
• CTA start: [Date] [Time] (Include only if obtained.)
• CTA interpreted: [Date] [Time] | Interpreter: [Name] | [Preliminary / Final]
• Perfusion imaging: [Date] [Time] | Interpretation: [Date] [Time] (Include only if obtained.)
• Thrombolysis decision: [Date] [Time] | Decision: [Eligible / Not eligible]
• Thrombolytic administration: Bolus [Date] [Time] | Infusion [Start time – End time] (Include only if given.)
• Neurointerventional consult: [Date] [Time] | Decision: [Proceed / Not a candidate / Observe]
• Transfer acceptance: [Date] [Time] | Receiving center: [Name] (Include only if applicable.)
• Transport: Depart [Date] [Time] | Arrive [Date] [Time]
• Groin puncture: [Date] [Time] (Include only if thrombectomy performed.)
• Reperfusion achieved: [Date] [Time] | Grade: [TICI grade]
• Handoff: [Date] [Time] | Receiving team: [Unit/service]

History of Present Illness

[Chief concern and stroke-focused narrative anchored to LKW, including onset, progression, fluctuation, associated symptoms, and functional impact] (Use direct quotes when they clarify timing or uncertainty.)

[LKW narrative: who witnessed, what "normal" means for this patient, credibility assessment] (For wake-up/unwitnessed strokes, document both last seen normal and time found abnormal.)

[Stroke mimic considerations if relevant: hypoglycemia, seizure/post-ictal, migraine aura]

[Antithrombotic medications with last dose times]

[Contraindication-relevant history: prior ICH, recent surgery/trauma, bleeding history] (If history unobtainable, state limitations and collateral attempts.)

Prehospital/Transfer Information

(Include only if applicable; omit entire section if no EMS or transfer information exists.)

• Mode of arrival: [EMS / Private vehicle / Inpatient recognition / Transfer] | Prenotification: [Yes / No]
• Prehospital stroke screen: [Scale name and result]
• Prehospital vitals/glucose: [BP, HR, SpO2, glucose] at [Time]
• Prehospital treatments: [Interventions given]
• Transfer packet key points: [Outside imaging times/results, thrombolytic given prior to arrival, LKW documentation source]

Relevant Background

(Focused items that influence eligibility and risk.)

• Vascular risk factors: [AF, prior stroke/TIA, HTN, DM, HLD, smoking, other]
• Bleeding risk factors: [Prior ICH, recent surgery/trauma, bleeding diathesis, GI bleeding, uncontrolled HTN, other]
• Antithrombotic regimen: [Anticoagulant type, dose, adherence, last dose time; antiplatelet agents; INR if on warfarin]
• Contrast allergy: [Yes / No / Unknown] (Include reaction type if known.)
• Baseline neurologic function: [Mobility, communication, ADLs, cognitive baseline]

Vital Signs

• Initial vitals: [Date] [Time] — BP [value], HR [value], RR [value], Temp [value], SpO2 [value], Glucose [value]
• Most recent vitals: [Date] [Time] — BP [value], HR [value], RR [value], Temp [value], SpO2 [value], Glucose [value]
• Weight for dosing: [kg] | [Measured / Estimated]

Neurologic Examination

(State if limited by intubation, agitation, aphasia, sedation, or other factors.)

• Level of consciousness: [Findings]
• Speech/Language: [Aphasia type, dysarthria, comprehension, fluency, naming, repetition]
• Cranial nerves: [Pupils, gaze, visual fields, facial symmetry]
• Motor: [Strength, tone, drift, asymmetry]
• Sensory: [Light touch, pain, neglect, asymmetry]
• Coordination: [Ataxia, finger-nose-finger, heel-knee-shin]
• Gait: [Findings / Not assessed due to acute status]

NIHSS

(Include for suspected ischemic stroke. If not performed or not valid, document reason and provide alternative severity description.)

• Performed: [Yes / No] | Date: [YYYY-MM-DD] Time: [HH:MM] | Examiner: [Name/role]
• Total score: [0–42]
• Items: 1a LOC [score], 1b LOC Questions [score], 1c LOC Commands [score], 2 Best Gaze [score], 3 Visual [score], 4 Facial Palsy [score], 5a Motor Arm Left [score], 5b Motor Arm Right [score], 6a Motor Leg Left [score], 6b Motor Leg Right [score], 7 Limb Ataxia [score], 8 Sensory [score], 9 Best Language [score], 10 Dysarthria [score], 11 Extinction/Inattention [score]
• If not performed/not valid: [Reason] | Alternative severity description: [Summary]

Diagnostics

(Prioritize results that informed decision-making. If pending at time of thrombolysis decision, state "Pending at time of decision.")

Laboratory Results

• POC Glucose: [Value with units] at [Date] [Time]
• Platelets: [Value] at [Date] [Time] | [Final / Pending]
• PT/INR: [Values] at [Date] [Time] | [Final / Pending]
• aPTT: [Value] at [Date] [Time] | [Final / Pending]
• Creatinine/eGFR: [Values] at [Date] [Time] | [Final / Pending] (Include if contrast administered.)
• [Other pertinent labs as applicable]

Neuroimaging

NCCT Head:

• Obtained: [Date] [Time] | Interpreted: [Date] [Time] by [Interpreter] | [Preliminary / Final]
• Findings: [Hemorrhage present/absent, early ischemic changes, ASPECTS if used]

CTA Head/Neck: (Include only if obtained.)

• Obtained: [Date] [Time] | Interpreted: [Date] [Time] by [Interpreter] | [Preliminary / Final]
• Findings: [LVO location/side or no LVO, stenosis, dissection]

CT Perfusion: (Include only if obtained.)

• Obtained: [Date] [Time] | Interpreted: [Date] [Time]
• Summary: [Core/penumbra mismatch as reported]

MRI Brain: (Include only if obtained.)

• Obtained: [Date] [Time] | Interpreted: [Date] [Time]
• Findings: [DWI/FLAIR mismatch, hemorrhage, diffusion restriction location]

Assessment

• Working diagnosis: [Suspected AIS / ICH / TIA / Mimic] — [Brief rationale]
• Localization: [Hemispheric/lobar/brainstem/cerebellar; vascular territory]
• Key decision drivers: [LKW and time window, disabling vs non-disabling deficit, imaging findings, anticoagulant status, inclusion/exclusion factors]
• Differential: [Brief differential with reasoning] (Include if applicable.)

Reperfusion Decision-Making

(Must include explicit decision statements. Do not leave this section blank.)

Thrombolysis Eligibility

• Time window determination: [LKW and calculated window; source and certainty; label if computed/estimated]
• Inclusion criteria: [Criteria met per local protocol]
• Contraindication screening:
  • Absolute: [Present / Absent] — [Supporting data]
  • Relative: [Present / Absent] — [Risk/benefit consideration]
  • Unknown data: [Specify what is unknown and mitigation attempts]
• Decision statement: [IV thrombolytic given. / IV thrombolytic not given because: (specific reason).] (Use one explicit sentence.)

Consent Discussion

(Include when thrombolytic offered, given, or refused.)

• Participants: [Patient, surrogate, interpreter] | Time: [Date] [Time]
• Capacity: [Assessment finding]
• Discussion: Risks, benefits, and alternatives discussed.
• Outcome: [Consented / Refused / Deferred] — [Reason if applicable]

Thrombolytic Administration

(Include only if thrombolytic given.)

• Agent: [Tenecteplase / Alteplase] | Weight: [kg] [Measured / Estimated] | Dose: [Calculation and mg]
• Bolus time: [Date] [Time] | Infusion: [Start time – End time] (if applicable)
• Peri-administration BP: Pre-bolus [value], during [value] | Interventions: [Antihypertensives given]
• Immediate tolerance: [Tolerated without complication / Complications: headache, angioedema, other] | Actions: [Details]
• Post-thrombolysis plan: Neuro checks q[interval], BP goal [target], antithrombotics held for [duration], follow-up imaging [timing and purpose]

Mechanical Thrombectomy Pathway

(Include when LVO is suspected or confirmed.)

Candidacy Evaluation

• LVO status: [Location/side] via [CTA / MRA / Other] | [No LVO identified]
• Severity: NIHSS [score] | Pre-stroke function: mRS [score]
• Time window: [Early window ≤6h / Extended window with criteria used]
• Consult time: [Date] [Time] | Decision: [Proceed to thrombectomy / Not a candidate because: (reason)]

Procedure/Transfer Details

(Include only if thrombectomy pursued.)

• Accepting center/operator: [Name]
• Transfer: Depart [Date] [Time] | Arrive [Date] [Time]
• Groin puncture: [Date] [Time]
• Reperfusion: [Date] [Time] | TICI grade: [Grade] | Complications: [None / Details]
• Post-procedure: BP goal [target], neuro checks q[interval] | Destination: [ICU / Stroke unit]

Additional Acute Management

(Include only items relevant to this stroke alert.)

• Airway/monitoring: [Airway status, oxygen, cardiac monitoring]
• Glucose management: [Interventions if abnormal]
• Blood pressure management: [Targets and agents; aligned with reperfusion plan]
• Antithrombotic plan: [Start/hold strategy; post-thrombolysis restrictions]
• Hemorrhage pathway: [Reversal agents, dosing, times; neurosurgery involvement] (Include only if ICH.)
• Swallow status: [NPO until screen / Screen completed with result]

Handoff and Disposition

• Destination: [ICU / Stroke unit / IR / Transfer / Floor / Discharge]
• Neuro status at handoff: [NIHSS or deficit summary] | Time: [Date] [Time]
• Imaging summary: [Known findings] | Pending: [Studies awaiting final read]
• Therapies given: [Thrombolytic agent and time; thrombectomy status; BP medications]
• Monitoring requirements: [Neuro check frequency, BP parameters, other protocols]
• Restrictions/precautions: [Post-thrombolytic bleeding precautions, antithrombotic resumption timing, follow-up imaging]
• Consultants: [Services involved and pending discussions]
• Family communication: [Who updated, when, content summary]
• Code status/goals of care: [Addressed / Not addressed; details if discussed]

Addendum

(Use for updates such as final radiology reads differing from preliminary interpretations, or new information impacting eligibility or diagnosis.)

• Addendum: [Date] [Time] — [Update and implications for care]