Discharge Summary

Discharge Summary Template

Please use the above template for discharge summaries. It is meant to be read and used in a modular fashion - i.e. take the pieces that you need and omit the parts that you don't need. Overall, the concept is that this is an issue based course in hospital, where all of the medical issues the patient encounters are outlined, including initially the stroke as the index event, and subsequent medical events. There is also a section for incidental findings, given that many stroke patients have incidental finding such as a thyroid nodule or a lung nodule.

Make sure to always review the medications when you are doing the discharge summary, as a principal, please do not prescribe more than 30 days of medications, and less it is very clear what the treatment plan is. This ensures that the patient follows up with her family physician rather than continue on her medication.

Please pay extra attention for medications, to antihypertensives, antithrombotics, and anti-coagulants. All of the above are best understood, when you spend some time during discharge to ensure that you understand why the patient had a stroke, as the mechanism of stroke is entirely very important.

Thank you for using this discharge summary template, email stroke@codestroke.net for any suggestions or revisions.

Course in hospital:

The following is an Issue-based course in hospital:

1) STROKE

Diagnosis:

[Acute Ischemic Stroke (AIS) / Transient Ischemic Attack (TIA) / Intra-cerebral Hemorrhage (ICH) / Retinal infarct / Amaurosis fugax / Acute ischemic myelopathy / Cerebral venous sinus thrombosis / Non-traumatic Sub-arachnoid Hemorrhage (non-TBI SAH)]

Main neurological deficits:

[Free text brief description, e.g mild/severe right arm and leg weakness]

[option 1]

Etiology/Suspected cause for Acute Stroke:

[Large artery atherosclerosis (≥50% stenosis) / Cardiac embolism (excluding PFO or other rare cardiac causes) / Small vessel disease / Cervical artery dissection / PFO (only cause and <3 vascular risk factors) / Other determined etiology / More than one possible etiology / Unknown etiology despite complete evaluation / Unknown etiology with incomplete evaluation / Stroke or TIA mimic]

[option 2]

Etiology for Intra-cerebral Hemorrhage (ICH):

[Small vessel disease / Amyloid Angiopathy / Anticoagulant / anti-thrombotic treatment (i.e. anti-platelet therapy) / Vascular lesion / Other]


Stroke Treatment:

-iv tPA [include details where possible]

-endovascular therapy (EVT) [include details where possible]

-Standard Medical Care [Anti-platelet agents, Anticoagulation, Antihypertensives, and statin therapy]

Pertinent Imaging:

*Research study participation: [Only include if answer is yes and indicate research study]


2) MEDICAL ISSUES (issue and plan):

- A Fib

-NSTEMI/MI

- CHF

- DVT/PE

-Pneumonia


3) INCIDENTAL FINDINGS:

Please see the imaging section, where imaging reports are available as part of this discharge summary.

[option 1]

You have been found to have a thyroid nodule, this requires follow-up, we request that you please see your family physician within 2 weeks, such that this can be addressed with a referral to either head and neck surgery, or an endocrinologist for appropriate testing, or both. It is quite important that you please follow-up on your thyroid nodule.

[option 2]

You have been found to have a lung nodule, this requires follow-up, we request that you please see your family physician within 2 weeks such that this can be addressed with a referral to either respiratory medicine, or another physician, as required for additional appropriate testing. It is quite important that you please follow-up on your lung nodule.


4) DISPOSITION

Discharge mRS:

0 No symptoms (able to carry out all usual activities)

1 No significant disability (able to carry out all usual activities despite some symptoms)

2 Slight disability (able to look after own affairs and perform ADLs without assistance)

3 Moderate disability (requires some help with ADLs but able to walk independently – cane or walker is permitted)

4 Moderate-severe disability (unable to attend to own bodily needs without assistance; unable to walk unassisted)

5 Severe disability (requires constant nursing care, bedridden, incontinent, unable to be left alone for a few hours)

Discharge destination: [Home / Rehabilitation / Other acute care hospital / Nursing home or palliative care centre or other medical facility]

Follow-up Plan:

For ALL of our Patients - Family Doctor Follow-up after being in hospital:

For all of our patients, because you have recently been to hospital, we request that you please follow-up with your family physician within 1-2 weeks of discharge.

Please call your family physician's office and book an appointment to be seen in follow-up. If you do not have a family physician, please obtain a family physician. In the interim, please see a walk-in clinic within 1-2 weeks to ensure that you are clinically stable, and there are no outstanding issues, and if at the discretion of the physician, you require, then you may be needing some additional testing such as blood work. One of the key items to have follow-up after discharge, in the setting of stroke, is your blood pressure, and we recommend that you have close follow-up after discharge with regard to this issue.

**We reviewed the symptoms and signs of TIA and Stroke, and the patient knows to call 911 should they experience a sudden onset of any focal neurological deficits. **


1) STROKE

For stroke treatment and prevention, you have been started on the following agents:

[option 0 - Single Antiplatelet]

You have been started on a SINGLE antiplatelet - for TIA or minor stroke: You have been started on Aspirin 81mg daily. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications

[option 1 - DAPT 3 Weeks then Clopidogrel]

You have been started on - DUAL antiplatelet therapy for TIA or minor stroke: You have been started on Aspirin 81mg daily and Clopidogrel (also called PLAVIX) 75mg daily - for a Total of 3 weeks. Please discontinue ASA at the end of 3 weeks and continue to take Clopidogrel (PLAVIX) 75mg indefinitely. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications

[option 2 - DAPT 3 Weeks then ASA]

You have been started on - DUAL antiplatelet therapy for TIA or minor stroke: You have been started on Aspirin 81mg daily and Clopidogrel (also called PLAVIX) 75mg daily - for a Total of 3 weeks. Please discontinue Clopidogrel (PLAVIX) at the end of 3 weeks and continue to take ASA 81mg indefinitely. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications

[option 3 - DAPT 3 months then Clopidogrel]

You have been started on - DUAL antiplatelet therapy for symptomatic, severe intracranial atherosclerosis. Please continue to take aspirin 81 mg p.o. daily, along with Clopidogrel (also called PLAVIX) 75 mg p.o. daily, together for a total duration of 3 months. After 3 months, continue on Clopidogrel (also called PLAVIX) 75 mg orally daily. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications

[option 4 - DAPT 3 months then ASA]

You have been started on - DUAL antiplatelet therapy for symptomatic, severe intracranial atherosclerosis. Please continue to take aspirin 81 mg p.o. daily, along with Clopidogrel (also called PLAVIX) 75 mg p.o. daily, together for a total duration of 3 months. After 3 months, continue on Aspirin 81 mg orally daily. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications

[option 5 - Apixaban]

You have been started on - Apixaban (also called ELIQUIS) (LU code 448) You have been started on apixaban, a twice daily oral anticoagulant drug, for stroke prevention in atrial fibrillation. The standard dose is 5mg twice daily. Good compliance is essential for the drug to be effective. While taking apixaban, renal function should be monitored regularly (at least several times a year) and additionally when clinically indicated. Apixaban should be used at a reduced dose of 2.5mg BID if 2 out of 3 of the following criteria are present: Age>80; wt<60kg and creat >133umol/L. Apixaban use is not recommended if eGFR is <25 ml/min …and your eGFR is……

For additional information on Anticoagulants, and what to expect about issues such as side-effects, please refer to the following Heart and Stroke website address at: https://www.heartandstroke.ca/heart/treatments/medications/anticoagulants

[option 6 - Rivaroxaban]

You have been started on - Rivaroxaban (also called XARELTO): (LU code 435) You have been started on rivaroxaban, a once daily oral anticoagulant drug for stroke prevention in atrial fibrillation. The standard dose is 20mg daily. Good compliance is essential for the drug to be effective. While taking rivaroxaban, renal function should be monitored regularly (at least several times a year) and additionally when clinically indicated. Rivaroxaban should be used at a reduced dose of 15mg daily if eGFR is 30-49ml/min. Rivaroxaban use is not recommended if eGFR is <30 ml/min …and your eGFR is……

For additional information on Anticoagulants, and what to expect about issues such as side-effects, please refer to the following Heart and Stroke website address at: https://www.heartandstroke.ca/heart/treatments/medications/anticoagulants

[option 7 - Warfarin]

You have been started on WARFARIN as a blood thinner, it is quite important that you take your dose daily for this medication. he use of warfarin should not interfere with a healthy diet. However it is important not to have large day-to-day variations in the amount of vitamin K which is found in foods such as kale, broccoli, spinach, turnip greens, Brussels sprouts. Therefore it you can eat any of these things however your diet must be consistent in the amount of leafy green vegetables such that the amount of vitamin K is stable because vitamin K reduces the efficacy of warfarin. For warfarin, your target INR is [FILL TARGET INR] - with a range of [FILL RANGE] -the INR, known as the international eyes normalized ratio, is a way of expressing how thin your blood is, and therefore measurement is required to make sure that your blood is adequately thin while on this medication. When initially starting on this medication he takes regular blood work, measuring the INR on a daily basis even, as it becomes more stable, weekly or a couple of times monthly is all that is needed to ensure that your INR is within the therapeutic limit.

For additional information on Anticoagulants, and what to expect about issues such as side-effects, please refer to the following Heart and Stroke website address at: https://www.heartandstroke.ca/heart/treatments/medications/anticoagulants

[ADDITIONAL SECONDARY PREVENTION AGENTS - For ALL Patients]

For stroke treatment and prevention, you have been started on the following ADDITIONAL agents:

You have been started on a statin agent: [STATIN]. We request that you follow-up with your family doctor with re-assessment and repeat bloodwork for liver/lipid profiles and CK in 3 months then annually. For Cholesterol and post-stroke risk modification: Your targets are a total cholesterol <4.0 and LDL <2.0.

Treatment with medications such as statins can cause common complaints such as muscle pain. You may feel pain as soreness, tiredness or weakness in your muscles. In general the actual risk of developing muscle pain as a result of taking a statin is about 5% or less. Studies have found that people stop taking this medication up to 30% because of muscle aches even when it was not due to this medication and they were on a placebo medication. Nonetheless, if you are having severe muscle aches, muscle pain, please see her physician for additional follow-up. Very rarely statins can cause a life-threatening illness, muscle injury called rhabdomyolysis, which can cause liver damage, kidney failure and even death. The risk of this very serious side effect is extremely low, it is a few cases per millions of patients, however this is a known risk and you should be aware of it. Liver damage or injury can occur with statin therapy, however this is again extremely rare, which is why we recommend you follow-up with your family physician in approximately 3 months for follow-up and blood work as outlined above.

Please see your family doctor - suggest monitoring of electrolytes and Creatinine when started on medications belonging to the class of ACEi (ACE Inhibitors)/ARBs (Angiotensin receptor blockers) and diuretics ("water pills").


2) Investigations pending - the following tests are pending:

Labwork (A1C, Lipid Profile)

Hypercoaguable screening

Auto-immune serology

CT

CT angiogram

MRI brain

MR angiogram

MR venogram

MR vessel wall imaging

Carotid dopplers

Transcranial dopplers for microemboli detection

TTE (Trans-thoracic Echocardiogram)

TEE (Trans-esophageal Echocardiogram

24-48 hour Holter monitoring

Prolonged Holter monitoring

Overnight Polysomnogram (sleep study)

EEG

EMG/NCS

Brain SPECT


3) Driving information:

[option 1]

At this time, you do not require reporting to the ministry of transportation, using the medical condition report (as outlined as of July 2018 regulations) - Because you do not have significant motor/physical impairment, cognitive impairment or visual field impairment - If you use corrective vision for driving, please ensure that you use corrective vision when driving. Should your medical status change or you have any additional or new medical problems a physician needs to please reassess you for driving, and you should hold driving (i.e. Do not Drive) until that assessment has been completed. If you have return of any stroke-like symptoms, please see a physician, and you are not to drive for 1 month until reassessed by a physician.

[option 2]

You are instructed not to drive for 1 month, until reassessed by a physician. You may be seen in the stroke prevention clinic as outlined below, if there is not a stroke prevention clinic appointment within 1 month or at the one-month mark, please see her family physician before resuming driving.

[option 3]

You are instructed not to drive, you have been reported to the ministry of transportation, as per the legal requirement to report patients with stroke who have any of motor or physical impairment, cognitive impairment or visual field impairment, or at risk of stroke, or if there is concern by the physician team that the patient is at risk of a motor vehicle collision or safety of self or others. Please do not drive until you are reassessed at the prevention clinic. Once you have received your forms from the ministry of transportation, and you are medically stable, any physician including family physician, or stroke physician at the stroke prevention clinic or TIA clinic can complete your forms.


4) Follow-up plan:

For ALL of our Patients - Family Doctor Follow-up:

For all of our patients, because you have recently been to hospital, we request that you please follow-up with your family physician within 1-2 weeks of discharge.

Please call your family physician's office and book an appointment to be seen in follow-up. If you do not have a family physician, please obtain a family physician. In the interim, please see a walk-in clinic within 1-2 weeks to ensure that you are clinically stable, and there are no outstanding issues, and if at the discretion of the physician, you require, then you may be needing some additional testing such as blood work. One of the key items to have follow-up after discharge, in the setting of stroke, is your blood pressure, and we recommend that you have close follow-up after discharge with regard to this issue.


Stroke prevention clinic appointment Date:

[option 1]

You have been referred to the Stroke Prevention Clinic at Sunnybrook on:

SUNNYBROOK HOSPITAL: TIA/Post-Discharge Stroke Clinic, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue - A-wing, 2nd floor, room A-233, Toronto, ON M4N 3M5, If you do not hear from the Stroke Prevention Clinic within 2 week from discharge, or you miss our call, please call the clinic at: 416-480-6100 x 89124.

[option 2]

Stroke Prevention Clinic will be arranged for you on discharge from your home hospital. At the time of discharge from Sunnybrook you are being transferred to your home hospital. For convenience we have listed the contact of your destination hospital's Stroke/TIA Prevention Clinic:

[option 3]

MACKENZIE HOSPITAL: Mackenzie Health, 10 Trench St., Richmond Hill, ON L4C 4Z3, The Clinic will attempt to contact you with the date and time of your appointment within 1-3 business days following your visit to the emergency department or Family Doctor. If you do not hear from the Stroke Prevention Clinic within 1 week from discharge, or you miss our call, please call the clinic at: (905) 883-1212 x7721 from Monday to Friday, 8am to 4pm

[option 4]

NORTH YORK HOSPITAL: Stroke Prevention Clinic, The key focus of the Stroke Prevention Clinic is secondary stroke prevention and health promotion. The clinic addresses risks and provide early intervention and education to patients. A nurse practitioner works alongside neurologists to provide care for stroke patients. Our goal is to manage the growing incidence of stroke in the community by improving the patient's quality of life through education, treatment and support. General site, Tel: 416-756-6000 4001 Leslie Street, Toronto ON M2K 1E1