What is the best way to document an in-office stroke assessment using a standardized template, including patient history, symptoms, physical exam findings, and National Institutes of Health Stroke Scale (NIHSS) results?

Standardized Documentation for In-Office Stroke Assessment

The most effective way to document an in-office stroke assessment is to use the National Institutes of Health Stroke Scale (NIHSS) as the standardized template, which provides a comprehensive, quantifiable neurological examination that can be completed in 5-8 minutes and facilitates clear communication between healthcare providers. 1, 2

Essential Components of Stroke Assessment Documentation

1. Patient History Documentation

Document the following key historical elements:

• Time of symptom onset (or last known normal) 3
• Initial symptoms and progression 3
• Vascular risk factors (hypertension, diabetes, hypercholesterolemia, smoking) 3
• Medications (especially anticoagulants, antiplatelets, decongestants, antihypertensives) 3
• Recent trauma or surgery 3
• Family history of stroke or vascular disease 3
• Alcohol or illicit drug use 3
• History of seizures 3
• Previous stroke or TIA 3

2. Physical Examination Documentation

Record these essential physical findings:

• Vital signs (blood pressure, heart rate, temperature, oxygen saturation) 3
• General physical exam focusing on head, heart, lungs, abdomen, and extremities 3
• Cardiovascular examination (carotid bruits, arrhythmias, heart murmurs) 3

3. NIHSS Documentation

Document the complete NIHSS with scores for each component:

Item	Assessment	Score
1A	Level of consciousness	0-3
1B	Orientation questions	0-2
1C	Response to commands	0-2
2	Gaze	0-2
3	Visual fields	0-3
4	Facial movement	0-3
5	Motor function (arm) - Left & Right	0-4 each
6	Motor function (leg) - Left & Right	0-4 each
7	Limb ataxia	0-2
8	Sensory	0-2
9	Language	0-3
10	Articulation	0-2
11	Extinction/inattention	0-2
	Total NIHSS Score	0-42

3

4. Stroke Severity Classification

Document the stroke severity based on NIHSS score:

• Small stroke: NIHSS <5
• Moderate stroke: NIHSS 5-15
• Large stroke: NIHSS >20
• Severe stroke: NIHSS >16 1

5. Additional Assessment Documentation

• Functional status (using Barthel Index if appropriate) 3
• Swallowing assessment results 3
• Cognitive and communication deficits 3
• Depression screening results 3

Implementation Tips for Effective Documentation

1. Use a standardized template that includes all NIHSS components to ensure consistent documentation 4

2. Ensure proper training for all providers administering the NIHSS to maintain reliability 1, 5

3. Document serial assessments to track changes over time:

   • Complete evaluation at admission
   • Follow-up assessments at appropriate intervals based on patient condition 1

4. Include interpretation of the NIHSS score and its implications for prognosis and management 1

5. Document any limitations in performing the assessment (e.g., patient unable to follow commands due to aphasia) 1

Common Pitfalls to Avoid

• Including prior deficits in scoring rather than focusing on acute changes 1
• Underestimating posterior circulation strokes (NIHSS may not fully capture these) 1
• Failing to reassess and document changes in neurological status 1
• Using untrained personnel to perform and document the assessment 1
• Relying solely on NIHSS without considering other clinical factors 1

By following this standardized approach to documenting in-office stroke assessments, healthcare providers can ensure comprehensive evaluation, facilitate communication between team members, track patient progress, and guide appropriate management decisions based on evidence-based guidelines.