Recommended standard of discharge report for stroke patients

Česká verze

Authors: R. Mikulík M. ^1,2; Šrámek M. ^1,3,4; ; Bar J. ^1,5; Neumann M. ^1,6; Kovář P. ^1,7; Reková ^1,8; D. Součková ^1,7,9; D. Šaňák D. ^1,10; Školoudík O. ^1,11; Škoda A. ^1,12,13; Tomek D. ^1,4; Václavík ^1,14; R. Herzig ^1,15,16
Authors place of work: Výbor Cerebrovaskulární sekce České neurologické společnosti ČLS JEP ¹; Neurologické oddělení, Nemocnice T. Bati, Zlín ²; Neurologické oddělení, ÚVN, Praha ³; Neurologická klinika 2. LF UK a FN Motol, Praha ⁴; Neurologická klinika LF OU a FN Ostrava ⁵; Neurologické oddělení, Krajská zdravotní, a. s., Nemocnice Chomutov ⁶; Neurologické oddělení, Nemocnice Na Homolce, Praha, ¨ ⁷; Neurologická klinika 1. LF UK a VFN v Praze ⁸; Sonolab, a. s. ⁹; Neurologická klinika, Komplexní cerebrovaskulární centrum, LF UP a FN Olomouc ¹⁰; Centrum vědy a výzkumu, Fakulta zdravotních věd, UP Olomouc ¹¹; Neurologické oddělení, Nemocnice Jihlava ¹²; Neurologická klinika 3. LF UK a FN Královské Vinohrady, Praha ¹³; Neurologické oddělení, Vítkovická nemocnice a Vzdělávací a výzkumný institut AGEL, Ostrava ¹⁴; Neurologická klinika LF UK v Hradci Králové ¹⁵; Neurologická klinika, Komplexní cerebrovaskulární centrum, FN Hradec Králové ¹⁶
Published in the journal: Cesk Slov Neurol N 2025; 88(2): 125-131
Category: Doporučené postupy
doi: https://doi.org/10.48095/cccsnn2025125

Summary

Treatment options for patients with stroke have dramatically evolved in recent decades due to advances in recanalization therapy and other interventional procedures. While acute treatment of ischemic stroke has become highly standardized, there remains significant variability in the areas of secondary prevention and rehabilitation. The same applies to the management of patients with intracerebral hemorrhage. A key step toward achieving standardization across healthcare facilities is the unification of medical documentation, particularly discharge reports. This article presents a recommended standard for discharge reports for patients with both ischemic and hemorrhagic strokes. Its main goal is to ensure uniform quality of healthcare, improve communication among medical professionals, support secondary prevention, and facilitate digitalization and scientific research. The recommended standard defines the minimum set of essential information that every discharge report for stroke patients should contain. The document also includes templates for admission reports and epicrises, which reflect the requirements of the international RES-Q registry and can facilitate data collection. The implementation of this standard will not only reduce the administrative burden on physicians, but also enable better quality control of care and ensure compliance with current clinical guidelines. Standardizing documentation represents an important step toward optimizing stroke treatment and improving long-term patient outcomes.

Keywords:

stroke – standardization – discharge report – benchmarking – health information technology

Zdroje

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2. Ernst BP, Katzer F, Künzel J et al. Impact of structured reporting on developing head and neck ultrasound skills. BMC Méd Educ 2019; 19 (1): 102. doi: 10.1186/s12909-019-1538-6.

3. Ebbers T, Kool RB, Smeele LE et al. The impact of structured and standardized documentation on documentation quality; a multicenter, retrospective study. J Méd Syst 2022; 46 (7): 46. doi: 10.1007/s10916-022-01837-9.