(each area will need to decide who is going to be responsible for completion of each action point as each area has different set ups and teams

Stroke Team Clinic Review
Stroke Clinic Review
Guidance Notes

Six week health and social care assessment – Acute trust / Primary Care Trust/LA.
Standard Pre –appointment requests. All investigation requested on discharge, R-
Test etc.
BP monitored x 2 minimum and recorded in patient health plan
Individuals have continuing access to specialist stroke care and rehabilitation after leaving
hospital and continuing risk screening is implemented.
a. Individual medical needs assessments, care strategies including secondary prevention
are assessed and treatment plan actioned. b. All individuals are given appropriate information on lifestyle factors e.g. regular exercise, diet, reducing salt intake, avoiding excess alcohol, and stopping smoking. c. A comprehensive, multidisciplinary, and user centred needs assessment is carried out. d. All individuals for whom rehabilitation is indicated are always referred to a specialist rehabilitation team or needs assessed as soon as possible after appointment. f. Individual emotional needs are assessed alongside their medical and care e. Individuals have their individual psychological and support needs reviewed on a regular f. Needs for special equipment at home is assessed on an individual basis, and aids, adaptations and equipment are not always supplied as soon as possible.
Six month health and social care assessment – Acute trust / Primary care Trust/LA
Standard Pre – appointment requests
BP monitored 2 monthly by PCT and recorded in patient health plan.
Fasting lipid profile.
The individual and carer’s medium and longer-term support is evaluated.

a. Individual medical needs assessments, care strategies including secondary prevention
are re-assessed and treatment plan updated and actioned.
b. A comprehensive, multidisciplinary, and user centred needs assessment is carried out.
c. All individuals and their carers are given advice on re-enablement such as returning to
work, availability of transport and benefits when appropriate.
One year assessment – Primary care.
The individual and carer needs for long –term support are re-evaluated.
a. Individuals care strategies including ongoing secondary prevention are reviewed and
treatment plan is updated.
b. A comprehensive, multidisciplinary and user centred need assessment is carried out.
Including social care needs.
c. Individual psychological and support needs are reviewed and appropriate actions taken.


ECSN SF/JN/MK 2011-03-01 X:\Stroke\Stroke Rehab & Life After Stroke\Proforma
CONTACT DETAILS
Name:


OBSERVATIONS
OBSERVATIONS (as appropriate):
BP (sitting):

GENERAL APPEARANCE
SKIN CONDITION AND INTEGRITY
PAIN
Other:
Complete full physical assessment if deemed necessary

CURRENT MEDICAL ISSUES

KNOWN ALLERGIES:
Current medical issues and treatment plan:
Secondary prevention:
BP within target levels < 140 / 85mmHg <150/90mmHg <140/85 mmHg (Diabetics)
(Is the patient on long acting ACE inhibitors: Perindopril& Thiazide Diuretic / Indapamide)
TARGET BP SET……………

Blood cholesterol within normal limits: >3.5mmol or post MI considers cholesterol lowering drugs


ECSN SF/JN/MK 2011-03-01 X:\Stroke\Stroke Rehab & Life After Stroke\Proforma Current medications (including over the counter)
M


The greyed out medications are recommended drugs, unless contraindicated

Stroke Team Clinic Review
Stroke Team Clinic Review
ECSN SF/JN/MK 2011-03-01 X:\Stroke\Stroke Rehab & Life After Stroke\Proforma FUNCTIONAL ASSESSMENT
ABILITY/AIDS USED ETC
Mobility
Able to walk indoors
wheelchair
Transfers
Bed mobility
Self Care
Care Package
Self medicating Prompt Assist Administer (delete as applicable) Blister packs Domestic
Drink, meal & snack
prep
SLT
Speech and Language
(Is a SLT referral needed or ongoing management being provided) ECSN SF/JN/MK 2011-03-01 X:\Stroke\Stroke Rehab & Life After Stroke\Proforma
FUNCTIONAL ASSESSMENT CONTINUED
Psychological: Please tick for any problems occurring in the 6 months post discharge ticking the box
under the appropriate level of need.
Few/ Mild symptoms;
Moderate / persistent mood
Severe / complex
Service Referred To / Intervention Received: For the problems identified above, please show which
services were used or would have been used if available


Depression / Mood
ECSN SF/JN/MK 2011-03-01 X:\Stroke\Stroke Rehab & Life After Stroke\Proforma Other
Visual disturbance
(Is a referral to Thetford required) Financial/Benefits
HEALTH PROMOTION
SMOKING
Current

ALCOHOL:
RISK FACTORS
ADVICE/LEAFLETS GIVEN
OUTCOME OF CLINIC
Issue/Concern List
Action Plan
ECSN SF/JN/MK 2011-03-01 X:\Stroke\Stroke Rehab & Life After Stroke\Proforma
Outcome Measures Form Completed
Stroke Impact Scale … Score……………….

NIHSS Score:(if appropriate) … Score……………….
Send discharge letter to GP

Send discharge letter to GP with request to
monitor BP _____________________

Invite back to clinic in 3 months

Invite back to clinic in 6 months

Invite back to clinic at One year
… Review to be completed by Acute / PCT
Other: ________________________________

Present at Review; (please circle)
Doctor Present
Report Not
No access
available
required
Nurse Present
No access
available
required
Physio Present
No access
available
required
OT Present
No access
available
required
SLT Present
No access
available
required
Social worker
No access
available
required
Carer Present
No access
available
required
Other Present
No access
available
required

Does the review count as ‘full’ or ‘partial’?
Full Review
See below for definition.

Partial Review
A 'full review' is where all health professionals appropriate to patients needs, including
social worker, are present. (It would be acceptable for a stroke nurse to cover AHP
aspects if suitably qualified).
Where social workers are not available, social care information must be available to
inform the review and be discussed with the patient. If the patient’s health information
is made available to social care and discussed at the social care review, this would
also count as a full review. If the patient has no social care needs then a review
without social care may be classed as a full review.
Assessors
Signature:

Designation:

Clinic point (please circle):
Other --------------------------------------
ECSN SF/JN/MK 2011-03-01 X:\Stroke\Stroke Rehab & Life After Stroke\Proforma

Source: http://www.ecsnetwork.nhs.uk/documents/StrokeRehab/stroke%20assessment%20review%202011-03-09.pdf