progress note
suggestions

Impression:

Plan:

• Stroke Etiology: 

• Stroke medical treatment:

  • ASA Started

  • Started on DAPT (dual anti-platelet therapy)

  • Started on Heparin (UFH) | Started on LMWH

• Stroke work-up:

  • Lipid panel performed. Patient is started on a Statin.

  • ECHO: 

  • Holter: 

• Stroke workup - Imaging:

  • Repeat CTA:

  • MRI:

• Driving:

  • We will fill out a Ministry of Transportation (MoT) Medical Condition Report (July 2018 version) and the patient is aware not to drive and that reporting will be completed.

  • This patient does not require reporting to the MoT (Medical Condition Report, July 2018 version) at this time given absence of motor (physical impairment), cognitive impairment, or visual field impairment.

• Family/Patient Update: Discussion with the patient/SDM regarding findings and the treatment plan including other options (risks, benefits, alternatives). Discussed risks of bleeding with regards to ASA/Anticoagulation. Discussion occurred using lay language. All questions answered.

PATIENT PROFILE:

Patient seen and reviewed in person during bedside Stroke Team rounds.

Overnight issues as applicable, reviewed.
Vital sign value in AM rounds reviewed.
Labs reviewed (recent).
Medications reviewed - daily review.
Imaging reviewed (recent)

Discussed in Stroke multidisciplinary rounds, 0930-0945; Then 0945-1000 AM without Orange team colleagues for NVU Level 1 patients:
Meeting with Team lead, SW, OT, PT, SLP, MD Team. Discussed clinical status, discussed disposition plan.

CLINICAL PLAN:

Profile:
-

Patient seen and reviewed in person during bedside Stroke Team rounds.
Overnight issues as applicable, reviewed.
Vital sign value in AM rounds reviewed.
Labs reviewed (recent).
Medications reviewed - daily review.
Imaging reviewed (recent)

Discussed in Stroke multidisciplinary rounds, 0930-0945; Then 0945-1000 AM without Orange team colleagues for NVU Level 1 patients:
Meeting with Team lead, SW, OT, PT, SLP, MD Team. Discussed clinical status, discussed disposition plan.

CLINICAL PLAN:
-
-
-
-Medical care: DVTp, Diet, Activity Reviewed, Allied Health Team (PT, OT, Dietician) implementing their assessment-based plan - please see their notes for details.

Profile:
-

Patient seen and reviewed in person during bedside Stroke Team rounds.
Overnight issues as applicable, reviewed.
Vital sign value in AM rounds reviewed.
Labs reviewed (recent).
Medications reviewed - daily review.
Imaging reviewed (recent)

Exam:

-

Discussed in Stroke multidisciplinary rounds, 0930-0945; Then 0945-1000 AM without Orange team colleagues for NVU Level 1 patients:
Meeting with Team lead, SW, OT, PT, SLP, MD Team. Discussed clinical status, discussed disposition plan.

CLINICAL PLAN:
-
-
-
-Medical care: DVTp, Diet, Activity Reviewed, Allied Health Team (PT, OT, Dietician) implementing their assessment-based plan - please see their notes for details.

All discussions occurred using clear language and plain terms, opportunity was provided for the patient to ask questions, and their questions were answered, they were satisfied with the answers provided.

All discussions occurred using clear language and plain terms, opportunity was provided for the SDM to ask questions, and their questions were answered, they were satisfied with the answers provided.