Recommended standard of discharge report for stroke patients

Overview

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

This is an unauthorised machine translation into English made using the DeepL Translate Pro translator. The editors do not guarantee that the content of the article corresponds fully to the original language version.

 

Introduction

The treatment options for stroke patients have changed dramatically over the last three decades, largely due to the results of randomized clinical trials that have demonstrated the benefit of a number of treatments. The implementation of these treatments, particularly recanalization therapy and proper logistics, has led to the development of a fairly standardized patient management process, in ictal centers. New data suggest that standardization will be needed analogously for the acute management of patients with intracerebral hemorrhage. It is also clear from clinical practice that while a high degree of standardization has been achieved for procedures related to recanalization therapy, the degree of standardization of procedures is significantly lower for secondary prevention and subsequent rehabilitation. The path to achieving this standardisation is complex and involves the development and continuous updating of recommendations, systematic quality control of the care provided, and optimisation of the reimbursement system. Many of these measures have already been partially implemented. One of the key points that support the standardisation of procedures across hospitals is the standardisation of medical documentation.

With the development of information technology tools in medicine, the increasing pressure for proper medical record keeping, and the concomitant increase in administrative demands on physicians, various tools and techniques will increasingly be used to increase documentation efficiency and reduce the time burden associated with administration. These techniques are known as content importing technology (CIT) [1]. Examples of CIT are copy and paste functions, automated import of data from other parts of the electronic health record, templates or macros. The aim of this communication is to provide ict centers with templates that they can use to simplify the medical record keeping process for CMP patients. The main advantage of these templates is their structuring, which will not only ensure that ict centres do not neglect to report all the facts that should be part of the medical report, but will also contribute to a better readability of the report for other users of the medical discharge report. At the same time, we present here a draft "Recommendation" that should support the standardization of follow-up care for CMP patients.

The fundamental reasons for standardization have been outlined above. However, there are a number of other considerations which we summarise in the following text.

1)
Ensuring uniform quality of care: the proposed standard also serves as a checklist that can be used prospectively to ensure that important tasks are not omitted in the care of a particular patient. If physicians have clearly defined requirements for the content of the discharge report in advance, the likelihood of missing necessary diagnostic and therapeutic steps is reduced. This approach promotes adherence to best practices and reduces variability in the care provided.

2)
Ensuring better communication: presenting information in an identical, chronologically structured and simple manner allows for more efficient communication of information to other clinicians and effective sharing of information among healthcare professionals. A standardised format simplifies the navigation of documentation for GPs, specialists and rehabilitation teams.

3)
Improved secondary prevention: clearly articulated, structured recommendations for lifestyle changes, drug therapy and other measures will improve secondary prevention and help reduce the risk of recurrent stroke.

4)
Promoting digitisation and automation: in the future, the use of machine reading for automatic completion of registries, in our case RES-Q, is envisaged. The more relevant variables included in the discharge report, the less manual work will be required for data collection and analysis. RES-Q, together with Charles University, is developing a tool that aims to reduce the need for manual data entry into the RES-Q registry as much as possible.

5)
Facilitating scientific research: structured reports will ensure more complete information and allow easier data collection.

6)
Automatic checking of the correct procedure: in the future, it will be possible to create tools that will, for example, automatically check whether all procedures have been performed on a particular patient. Given the number of clinical studies that dictate clinical practice, their comprehensive knowledge and application is becoming increasingly challenging for most practicing neurologists. Tools that ensure compliance of care with extensive record keeping will greatly facilitate the work of clinicians.

Methodology

This guideline is not the result of a rigorous methodological approach. Two authors (MS, RM) produced a first version, which was subsequently commented on and approved by members of the Cerebrovascular Section Committee of the Czech Neurological Society.

In the selection of variables, the following facts of the ČLS JEP were taken into account:

a)
current medical recommendations supplemented by the results of recent clinical studies;

b) availability of the information;

c) information entered into the RES-Q registry;

(d) clinical practice patterns.

 

Results

Discharge report standard

Emphasis is placed on describing the clinical condition and acute treatment, determining the aetiology of the stroke and recommending further management. The recommended standard has two levels. The first is the content of the report, which is the minimum standard for all departments (Tables 1 and 2). It contains information on the clinical status at entry and exit, acute therapy, imaging results, the identified aetiology of the stroke and secondary prevention measures. The proposal specifies what information should be included in the discharge report on a mandatory basis, but whether it should be part of the diagnostic conclusion, the description of the course of hospitalisation or the recommendation for further action at discharge depends on the practice of individual departments. Examples of specific patients are given in Tables 3 and 4.

The second level consists of the admission report template and the epicrisis template, which go beyond the minimum standard in their content and serve more as methodological guidance (Tables 5 and 6). Both of these templates reflect the requirements of the RES-Q registry and can facilitate the entry of patient data into the registry. Below is an example of a discharge report for specific patients with ischemic and hemorrhagic stroke (Tables 5 and 6).

 

Discussion

These recommendations are the first attempt to standardize documentation for patients with stroke in the Czech Republic. We anticipate that this standard may be further revised and updated in the future based on new findings from randomized clinical trials and real-world experience in ict centers.

The proposed standard defines the minimum dataset that should be included in the discharge report. The document also provides a structured template for the recording of this data, which can be used by individual health care facilities either on their own or in combination with free narrative recording as they choose. The decision whether to supplement the structured documentation with narrative comments, whether for rational or traditional reasons, remains at the discretion of the individual facilities. However, there are currently no data available to show the benefit of expressive narrative documentation, which is currently considered the standard. In contrast, there are studies that have shown that the quality of structured records is higher than unstructured records and that structured documentation is clearer and more transparent. For example, one study showed that structured descriptions of head and neck ultrasound examinations were significantly more complete (97.7 vs. 53.5%), more detailed (70 vs. 51.1%) and easier to read (100 vs. 54.4%), took less time to complete (79.6 vs. 205.4 s) and were more user-friendly (8.5 vs. 4.1 points) [2]. Therefore, implementation of structured documentation in electronic records may be recommended to improve the quality of care and the possibility of secondary use of evidence-based data [3].

Health information technology (HIT) systems have also been shown to have the potential to improve the quality of patient care, for example, by reducing errors in the diagnostic process. According to different sources, these systems can be classified into different categories, e.g:

Tools that assist in the collection of information

                Facilitating cognition through better organisation and display of information

Assisting in the generation of differential diagnosis

                Tools and calculators to help in considering different diagnoses

                Support for intelligent indication of diagnostic tests/plans

                Better access to diagnostic reference information and guidelines

                Tools to facilitate reliable monitoring, assessment of progress and patient response

                Tools/alerts that support screening for early detection of disease in symptomatic patients

                Tools that facilitate collaboration with specialists

                Systems that facilitate feedback and quality/performance control

 

Our proposal for a standardized discharge report falls into several of the above categories and aims to reduce the risk of errors in the management of patients with CMP. We anticipate that this goal will be achieved by at least three mechanisms: a) allowing systematic verification that all important steps were performed during the hospitalization of a CMP patient; b) streamlining communication between members of the healthcare team; and c) improving benchmarking by facilitating data extraction into the RES-Q registry (currently performed manually and expected to be at least partially automated in the future).

In the future, standardisation will be helpful for the development of other HIT tools, such as automatic generation of a hospital summary (a test version already exists in RES-Q), automatic translation of this summary into different languages (planned for implementation, in RES-Q by 2026), automatic individualised prediction of functional status and possibly complications after CMP (will be in RES-Q in 2026, but release will be subject to regulatory requirements, in particular "medical device regulation").

 

List of abbreviations

ASPECT -⁠ Alberta Stroke Program Early CT score

ALT -⁠ alanine aminotransferase

CEA -⁠ carotid endarterectomy

CIT -⁠ content importing technology

CTP -⁠ perfusion CT scan

DIDO -⁠ door in door out

DGT -⁠ door to groin time

DNT -⁠ door to needle time

GCS -⁠ Glasgow Coma Scale

GLP-1 -⁠ Glucagon-like peptide-1

HIT -⁠ Health Information Technology

INR -⁠ International Normalized Ratio

IVT -⁠ intravenous thrombolysis

KCC -⁠ Comprehensive Cerebrovascular Centre

MDT -⁠ Medical Data Transfer

mRS -⁠ modified Rankin Scale

MT -⁠ mechanical thrombectomy

mTICI -⁠ Modified Thrombolysis in Cerebral Infarction perfusion scale

NIHSS -⁠ National Institutes of Health Stroke Scale

OTN -⁠ onset to needle time

OTR -⁠ onset to recanalisation time

PCSK9 -⁠ Proprotein convertase subtilisin/kexin type 9

RES-Q -⁠ Registry of Stroke Care Quality

TICI -⁠ Thrombolysis in Cerebral Infarction perfusion scale

BP -⁠ blood pressure

TOAST -⁠ Trial of ORG 10172 in Acute Stroke Treatment

ZZS -⁠ Emergency Medical Service

 

Most commonly used ICD codes for reporting stroke

Ischemic stroke:

I63.0 Cerebral infarction caused by thrombosis of the cerebral arteries

I63.1 Cerebral infarction caused by emboli of the cerebral arteries

I63.2 Cerebral infarction due to unspecified occlusion or stenosis of the cerebral arteries

I63.3 Cerebral infarction caused by thrombosis of cerebral arteries

I63.4 Cerebral infarction caused by cerebral artery embolism

I63.5 Cerebral infarction caused by unspecified occlusion or stenosis of cerebral arteries

I63.6 Cerebral infarction due to cerebral venous thrombosis' nonpurulent

 

Haemorrhagic stroke:

61.0 Intracerebral (intracerebral) hemispheric' subcortical hemorrhage

I61.1 Intracerebral (intracerebral) haemorrhage into the cortical hemisphere

I61.2 Intracerebral (intracerebral) haemorrhage into NS hemisphere

I61.3 Intracerebral (intracerebral) haemorrhage into the brainstem

I61.4 Intracerebral (intracerebellar) haemorrhage into the cerebellum

I61.5 Intracerebral (intracerebral) haemorrhage into cerebral ventricles

I61.6 Intracerebral (intracerebral) haemorrhage multiple localised

 

Conflict of interest

The authors (Martin Šrámek, Robert Mikulík, Michal Bar, Jiří Neumann, Martin Kovář, Petra Reková, Dagmar Součková, Daniel Šaňák, David Školoudík, Ondřej Škoda, Aleš Tomek, Daniel Václavík, Roman Herzig) have no conflict of interest.

 

Table 1.

basic diagnosis -⁠ ischemic stroke

localization of the lesion

date of onset

clinical manifestation

initial NIHSS

result of initial brain and cerebral artery imaging

acute treatment (IVT, MT, ...)

logistic data (DNT, DGT, OTR, OTN, DIDO)

result of follow-up brain imaging

etiology of ischemic stroke (according to SSS-TOAST), secondary prevention

discharge status

baseline NIHSS and mRS

place where the patient is discharged

recommendations for outpatient follow-up, checks and medication

DGT -⁠ door to groin time; DIDO -⁠ door in door out; DNT -⁠ door to needle time; IVT -⁠ intravenous thrombolysis; mRS -⁠ modified Rankin Scale; MT -⁠ mechanical thrombectomy; NIHSS -⁠ National Institutes of Health Stroke Scale; OTN -⁠ onset to needle time; OTR -⁠ onset to recanalisation time; SSS-TOAST -⁠ Trial of ORG 10172 in Acute Stroke Treatment

 

 

 

Table 2. Recommended minimum content of the discharge report of a patient with hemorrhagic stroke.

Primary diagnosis -⁠ haemorrhagic stroke

localization of the lesion

date of onset

clinical manifestation

initial NIHSS

the result of the initial imaging of the brain and cerebral arteries

acute treatment (normalisation of BP and coagulation, neurosurgery)

logistic data (normalisation of coagulation, achievement of BP < 140 mmHg)

outcome of follow-up brain imaging

aetiology of haemorrhagic stroke

discharge status

baseline NIHSS and mRS

place where the patient is discharged

recommendations for outpatient follow-up, checks and medication

mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; BP, blood pressure

 

 

Table 3. Discharge report template for patients with ischemic stroke. Required information is in bold, example of a specific patient in normal font.

Basic diagnosis	acute cerebral infarction
Pathology, localisation	M1 occlusion of the left ACM segment, CTP deficit: hypoperfusion 100 ml, core 20 ml, mismatch 80 ml
Date of onset	12/15/2024 at 9 : 00 a.m.
Clinical manifestation	right-sided hemiplegia, expressive aphasia
NIHSS score	14
Treatment	Intravenous thrombolysis and/or mechanical thrombectomy If recanalization was not performed, why it was not indicated
Logistics	DNT and DGT
Recanalization	TICI
Etiology	Cardioembolization (according to SSS-TOAST classification)
Follow-up brain imaging	CT or MRI: infarction in the area of the left insula
Condition at discharge	right-sided hemiparesis
NIHSS score at discharge	4
mRS score at discharge	2
Read more	e.g. early EAC indicated, provided with anticoagulation therapy (dabigatran 2×150 mg)
Place of discharge	Home
Example
Acute cerebral infarction at M1 ACM left closure, hypoperfusion 100 ml, core 20 ml. Onset on 12/15/2024 at 9 h. On admission right-sided hemiplegia and expressive aphasia, NIHSS 14. Intravenous thrombolysis -⁠ Actilyse 75 mg administered 18 min after admission and mechanical thrombectomy performed 55 min after admission (or patient transported to KCC for mechanical thrombectomy 40 min after admission). TICI 2b. Cardioembolization etiology in atrial fibrillation. According to follow-up brain CT, development of infarction in the area of the left insula. Secured with anticoagulation therapy with dabigatran 2×150 mg. On discharge, mild right-sided hemiparesis, NIHSS 2, mRS 2. Discharged home.   Recommendations Regular checks of BP (target values 130/80 mmHg), glucose, lipid spectrum (target LDL values below 1.4 mmol/l) by GP. Further dispensary care by GP, outpatient neurologist, in case of worsening of the condition or development of new symptoms, call A&E.   Possible further formulation of recommendations:    We recommend continuing established dual antiplatelet therapy (Anopyrine + Thrombex) for 3 weeks, followed by Anopyrine monotherapy. To investigate the cause of the stroke, long-term ECG monitoring should be added, which can be arranged through MDT-Medical Data Transfer, Ltd., International Centre for Telemedicine (tel. +420 514 514 480; e-mail:mdt@mdt.cz ; web: http://www.mdt.cz/). In case of detection of an arrhythmia (atrial fibrillation), anticoagulation therapy is indicated from a neurological point of view. In view of the statin administered, ALT levels should be checked by a general practitioner in about 8 weeks and a lipidogram should be checked: inclisiran is indicated for LDL-C > 2 mmol/l, alternatively PCSK9 inhibitors are indicated for LDL-C > 2.5 mmol/l. For LDL-C between 1.4-2 mmol/l, ask the GP to add ezetimibe. Follow-up in the vascular neurology outpatient clinic in our clinic/department on XX. XX. XXXX Appropriate regular follow-up with diabetologist, consider GLP-1 agonists. Regimen: Consistent use of recommended medication. Limit animal fats in the diet. Adequate hydration. Regular sleep schedule. Regular physical aerobic activity (walking). Patient instructed, understands. Patient has reduced ability to work, able to drive motor vehicle.

ACM, arteria cerebri media; ALT, alanine aminotransferase; CEA, carotid endarterectomy; CTP, perfusion CT scan; DGT, door to groin time; DNT, door to needle time; ECG, electrocardiography; KCC, Comprehensive Cerebrovascular Center; LDL, low-density lipoprotein; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; SSS-TOST, Trial of ORG 10172 in Acute Stroke Treatment; TICI, Thrombolysis in Cerebral Infarction perfusion scale; BP, blood pressure; EMS, Emergency Medical Service

 

 

Table 4: Template for discharge report of a patient with hemorrhagic stroke. Required data are in bold, example of a specific patient in normal font.

Basic diagnosis	intracerebral haemorrhage
Pathology, localization	in the basal ganglia on the left, frontal on the right, no source of bleeding on CTA, size 20 ml
Date of occurrence	15. 12. 2024
Clinical manifestation	right-sided hemiplegia, expressive aphasia
NIHSS score	14
Treatment	Conservative or surgical treatment
Logistics	Achievement of BP<  140 mmHg in 125 min from admission
Reversal of anticoagulation	idarucizumab administered
Etiology	Hypertensive, anticoagulation therapy, amyloid microangiopathy, etc.
Control brain imaging	CT or MT: no progression of bleeding
Status on release	mild right-sided hemiparesis
NIHSS score at discharge	4
mRS score at discharge	3
Read more	Re-installation of anticoagulation therapy due to high risk of thromboembolism and absence of microbleeds on control MRI
Discharge site	Home
Example
Acute intracerebral hemorrhage F left with no source of bleeding found on CTA, volume 20 ml. On admission, right-sided hemiplegia and expressive aphasia, NIHSS 14. Neurosurgical intervention not indicated due to size of hematoma. Reversal of anticoagulation with idarucizumab with DNT 15 min. IV antihypertensives started 15 min from admission, BP < 140 achieved in 125 min from admission. Etiology related to anticoagulant use. No progression of bleeding according to follow-up brain CT. On discharge mild right-sided hemiparesis and expressive aphasia, NIHSS 4, mRS 3. Discharged home.   Recommendations Regular BP checks by GP en route (target values 130/80 mmHg). Further dispensary care via the pathway of the general practitioner, outpatient neurologist, in case of worsening of the condition or development of new symptoms, call the Emergency Department. Follow-up in the vascular neurology outpatient clinic at our clinic/department on XX. XX. XXXX, prior to that a follow-up MRI of the brain to further investigate the cause (microbleeds, malformations, tumor)

mRS -⁠ modified Rankin Scale; MT -⁠ mechanical thrombectomy; NIHSS -⁠ National Institutes of Health Stroke Scale; BP -⁠ blood pressure; EMS -⁠ medical emergency service

 

 

 

Table 5: Template for the report of a patient with ischemic stroke reflecting the requirements of the RESQ registry.

Time of onset of stroke	9 : 00
Time and place of admission	10 : 00, CT
mRS before CMP	0
NIHSS on admission	18
CT time	10 : 05
ASPECTS	8
Older ischemic foci and localization	Yes; cortical/subcortical/brainstem
Pressure value (mmHg)
Time of IVT	10 : 15
Type and dose of drug (mg)	Actilyse/Metalyse
Place of IVT	CT scan/ICU/emergency room/urgent admission
If not performed, reason	mild deficit / outside time window / underwent elsewhere
DNT	15 min
Large artery occlusion	Yes
Indications for MT	Yes
Time of referral to KCC	10 : 45
Date and time of groin puncture
Complications during thrombectomy
mTICI after recanalization
GCS
Initial INR testing performed?	POC / laboratory / not performed
Location from where the patient arrived	Home
Epicrisis template
LDL mmol/l level (1st measurement in hospital):
Glycaemia level mmol/l (1st measurement in hospital):
Was the temperature measured above 37.5°C in the first 72 h?
If yes, was an antipyretic administered?
When after the elevated temperature was measured was it given?
Highest glycaemic level in the first 48 h after admission (including 1st measurement)
Was insulin given at first elevated level and when?
Was a swallow test performed and when (within 4 h, after 24 h, cannot be performed):
Complications after CMP
Prevention of thromboembolic disease
Did the patient undergo physiotherapy?
Did the patient undergo occupational therapy?
Has the patient undergone speech therapy?

ASPECTS, Alberta Stroke Program Early CT Score; GCS, Glasgow Coma Scale; INR, blood clotting test; IVT, intravenous thrombolysis; KCC, comprehensive cerebrovascular center; LDL, low-density lipoprotein; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; POC, point of care

 

 

 

Table 6: Template for the report of a patient with hemorrhagic stroke reflecting the requirements of the RESQ registry.

Time of onset of stroke	9 : 00
Time and place of admission	10 : 00 CT
mRS before CMP	0
NIHSS on admission	18
CT time	10 : 05
Older ischemic foci and localization	Yes: cortical/subcortical/brainstem
Pressure value (mmHg)	190
Bleeding volume (ml), localization	150, supratentorial
Other localization of bleeding and, if applicable, where:	subarachnoid/intraventricular
Antihypertensive administered at systolic BP > 140 mmHg?	Yes
Time of administration of antihypertensive drugs:	10 : 15
Was a systolic blood pressure <140 mmHg achieved and when?	Yes, 10 : 25 a.m.
Cause of bleeding	arterial hypertension
Neurosurgical intervention performed, if applicable, which one?	Partial evacuation of the hematoma
If not performed, why?	e.g. size of haematoma
GCS	14
Initial INR testing performed?	POCT / lab / not performed
Location from where the patient arrived:	Home
Epicrisis template:
LDL mmol/l level (1st measurement in hospital):
Glycaemia level mmol/l (1st measurement in hospital):
Highest blood pressure 24 h after admission:
Was temperature measured above 37.5 °C in the first 72 h?
If yes, was an antipyretic administered?
When after the elevated temperature was measured was it given?
Highest blood glucose level in the first 48 h after admission (including 1st measurement)
Was insulin given at first elevated level and when?
Was a swallow test performed and when (within 4 h, within 24 h, after 24 h, cannot be done):
Complications after CMP
Prevention of thromboembolic disease
Did the patient undergo physiotherapy?
Has the patient received occupational therapy?
Has the patient undergone speech therapy?

GCS, Glasgow Coma Scale; INR, blood clotting test; LDL, low-density lipoprotein; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale