Stroke/TIA Clinic Note

Date: [Date of visit]

Visit Type: [post-discharge follow-up / routine secondary prevention / urgent recurrence evaluation]

Data Sources: [Sources referenced today] (List as applicable: patient/caregiver interview, discharge summary, imaging reports, images personally reviewed, rhythm/device data, outside records.)

Chief Concern

[Reason for visit in patient-friendly terms] (1–3 lines. Include patient's stated goals if provided.)

History

[Interval history since last stroke-related evaluation] (Summarize any recurrent focal neurologic symptoms with timing/duration; intervening ED visits/hospitalizations; functional trajectory across mobility, speech/language, cognition, mood, and return to activities; medication adherence and barriers; and rehabilitation participation.)

[Index event anchor] (Initial visit: 2–4 lines. Follow-ups: 1–2 lines. Include event type [ischemic stroke / TIA], date, vascular territory, etiology status [determined / suspected / cryptogenic / under evaluation], acute treatments received, and discharge functional status.)

Current Medications: [Active antithrombotic(s) with dose and indication; statin with dose; key antihypertensives] (Note adherence, tolerability, and stop dates for time-limited regimens such as DAPT.)

Risk Factor Status: [BP (clinic and/or home average); LDL with date; A1c with date if diabetic; tobacco status; OSA status if known]

Objective

Vitals: [BP (repeat if elevated); heart rate; weight if relevant]

Exam: [Focused neurologic examination] (Include mental status/language, relevant cranial nerves, motor strength with pronator drift, sensory, coordination, gait/mobility; include functional status summary or mRS if used. For telehealth, state examination limitations.)

Data Reviewed: [Key imaging, cardiac studies, rhythm monitoring, and labs with dates and pertinent findings] (Specify "radiology report reviewed" vs "images personally reviewed" when relevant.)

Assessment

[Synthesis] (1–2 sentences stating index event type and territory, etiology status [determined / suspected / cryptogenic], workup status [complete / pending], and current prevention priorities.)

1. [Ischemic stroke/TIA with mechanism]
2. [Major vascular risk factors requiring attention]
3. [Stroke-related sequelae affecting function or safety] (Include only if present.)

Plan

(Organize by problem; write as actions: start/continue/change/order/refer. Include explicit targets, agents, and timelines. Omit elements not clinically relevant to this encounter.)

Secondary Prevention

• Etiology workup: [What is complete vs pending; next diagnostic steps and timing]
• Antithrombotic: [Agent(s), dose, indication, and planned duration] (If DAPT, specify stop date; include bleeding risk counseling.)
• Lipids: [Statin agent/dose; LDL target (typically <70); escalation plan if not at goal; timing for repeat lipids]
• Blood pressure: [Target (typically <130/80); medication adjustments; home BP instructions]
• Diabetes: [A1c target; medication coordination] (Include only if applicable.)
• Lifestyle: [Diet; activity; smoking cessation; OSA management as applicable]

Etiology-Specific

(Include only the applicable item below; omit section if no etiology-specific intervention needed.)

• AF/cardioembolic: [Anticoagulation choice/dose; renal dosing verification; cardiology coordination]
• Carotid stenosis: [Degree of stenosis; referral for intervention evaluation; timing]
• PFO: [Candidacy discussion; referral status; shared decision documentation]
• Cryptogenic/ESUS: [Rhythm monitoring plan and duration; document that empiric anticoagulation is not indicated absent AF]

Recovery & Rehabilitation

[Current therapies (PT/OT/SLP); functional goals; equipment/safety needs; management of sequelae (spasticity, pain, mood, cognition) as applicable]

Patient Education

[Reviewed stroke warning signs (FAST) and instruction to call 911 for new focal symptoms; antithrombotic safety counseling (bleeding signs, missed doses); BP home monitoring guidance] (Document teach-back if performed.)

Orders & Follow-up

[Tests ordered with timing and responsible reviewer; pending results; referrals placed; next appointment; return precautions (new neurologic symptoms → call 911)]

Missing Critical Information: [Unavailable items affecting safety/decisions and plan to obtain them] (Include only if applicable.)