Acute Form 2004 - Riks-Stroke (Page 4 of 4) in pdf

Acute Form 2004 - Riks-Stroke Page 4

B LATE MANAGEMENT (refers to continued rehabilitation of acute stroke within the same health care

system or institutional care)

B Date of admission I___I___II___I___II___I___I

(yy/mm/dd)

B Date of discharge I___I___II___I___II___II___I

(yy/mm/dd)

--------------------------- DISCHARGED TO following B LATE 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

6= deceased during hospital stay

7= other

9= not known

B Address and phone number whereto patient has been discharged (please text clearly) (optional)

…………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………….

-------------------------------------- COMPLICATIONS

------------------------------------

DURING HOSPITALISATION

alternative answers are 1= yes

2= no

9= unknown

Deep venous thrombosis / Pulmonary embolism

I___I

Fracture

I___I

Pneumonia

I___I

------------------------------------------------- STROKE DIAGNOSIS -----------------------------------------------------

Stroke diagnosis

I I___I___I.I___I

I 61 = intracerebral hemorrhage

I 63 = cerebral infarction

I 64 = unspecified acute stroke

G 45 =TIA/cerebral ischemia/transient within 24 h (optional).

I___I___I.I___I

--------------------------------------------- PLANNING OF CARE --------------------------------------------

alternative answers are 1= yes

2= no

9= unknown

Has the care and rehabilitation been planned by the county council institutional care?

I___I

Did the patient/next-of-kin partake in the planning?

I___I

--------------------------------------------------------- DECEASED ---------------------------------------------------------

To be filled in only if the patient died during the hospital stay

Date (date when the patient died) (yy,mm,dd)

I___I___II___I___II___I___I

Autopsy performed 1= yes 2= no 9= unknown

I___I

Acute Form 2004 - Riks-Stroke Page 4

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