Acute Form 2004 - Riks-Stroke Page 3
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4---------------------------------------------------- SEQUENCE OF CARE ------------------------------------------------
A
ACUTE MANAGEMENT (refers to the first episode of hospital care for the present stroke)
A Date of onset
I___I___II___I___II___I___I
I___I___I.I___I___I (hour, minute)
(yy/mm/dd)
Time of onset of symptoms
A Date of admission I___I___II___I___II___I___I
I___I___I.I___I___I (hour, minute)
(yy/mm/dd)
Time of arrival
First admitted to I___I
1= general ward
2= stroke unit
3= admisson/observation ward
4= intensive care unit
5= other (fill in). Other............................................................…………………………………………………
First department I___I
1= Medicine
2= Neurology
3= Geriatrics or rehab
4= Other
Continued care during the acute phase I___I
1= general ward
2= stroke unit
3= admisson/observation ward
4= intensive care unit
5= other (fill in). Other............................................................……………………………………………..……..
Subsequent department I___I
1= Medicine
2= Neurology
3= Geriatrics or rehab
4= Other
A Date of discharge I___I___II___I___II___I___I (yy/mm/dd)
-------------------------- DISCHARGED TO following A ACUTE MANAGEMENT --------------------------------
1= own home
I___I
2= a community facility (for instance service flat with full board, old peoples’ home, nursing home,
short term pension)
4= other acute-care department
5= geriatric/rehab = fill in section B LATE MANAGEMENT
6= deceased during hospital stay
7= other
9= not known
A Address and phone number whereto the patient has been discharged (please text clearly)(optional)
…………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………… …………
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