Stroke Assessment Template

What is the Gold Standard for Acute Stroke Assessment?

The National Institutes of Health Stroke Scale (NIHSS) is widely considered the gold standard for assessing acute stroke. It's a systematic tool that provides a quantitative measure of stroke-related neurologic deficit. Originally designed for research, the NIHSS is now extensively used in clinical practice to evaluate stroke severity, determine treatment eligibility (especially for thrombolysis), and predict patient outcomes. The scale assesses 11 items, including level of consciousness, best gaze, visual fields, facial palsy, motor arm and leg, limb ataxia, sensory function, language, dysarthria, and extinction/inattention. A key advantage of the NIHSS is its ability to provide a common language for communication among healthcare providers. For instance, a neurologist can understand the patient's baseline deficit from the initial NIHSS score documented by an emergency physician. Explore how integrating a standardized NIHSS template into your electronic health record can streamline this process and improve inter-departmental communication.

 

NIH Stroke Scale (NIHSS) Scoring Breakdown

 

Item	Description	Score Range
1a. Level of Consciousness	Alertness	0-3
1b. LOC Questions	Month and age	0-2
1c. LOC Commands	Open/close eyes, grip/release hand	0-2
2. Best Gaze	Horizontal eye movements	0-2
3. Visual Fields	Visual field testing	0-3
4. Facial Palsy	Facial movement symmetry	0-3
5. Motor Arm (Left/Right)	Drift or movement against gravity	0-4 (each)
6. Motor Leg (Left/Right)	Drift or movement against gravity	0-4 (each)
7. Limb Ataxia	Finger-nose and heel-shin testing	0-2
8. Sensory	Sensation to pinprick	0-2
9. Best Language	Aphasia assessment	0-3
10. Dysarthria	Speech clarity	0-2
11. Extinction/Inattention	Formerly "Neglect"	0-2

 

 

How Can You Quickly Assess for Stroke in a Pre-Hospital Setting?

In a pre-hospital or emergency setting, time is critical. Several simplified scales are used to rapidly identify potential stroke patients. The Cincinnati Pre-Hospital Stroke Scale (CPSS) is a well-known tool that assesses three key signs: facial droop, arm drift, and abnormal speech. If any one of these signs is abnormal, the probability of a stroke is high. Similarly, the FAST (Face, Arm, Speech, Time) acronym is a public-facing tool that is also widely used by first responders. Another valuable tool is the Los Angeles Prehospital Stroke Screen (LAPSS), which adds criteria like age over 45, no history of seizures, and blood glucose levels to improve specificity. These scales are not designed to measure stroke severity but to quickly identify patients who need immediate transport to a stroke-ready hospital. Consider implementing a checklist in your ambulance or emergency department that incorporates one of these validated pre-hospital scales to ensure no potential stroke patient is missed.

 

When Should You Suspect a Large Vessel Occlusion (LVO)?

Identifying a large vessel occlusion (LVO) early is crucial because these patients may be candidates for mechanical thrombectomy. The Rapid Arterial oCclusion Evaluation (RACE) scale was specifically designed for this purpose. It's a simplification of the NIHSS, focusing on items with a high predictive value for LVO. The RACE scale evaluates five key areas: Facial Palsy, Arm Motor Function, Leg Motor Function, Head and Gaze Deviation, and Aphasia/Agnosia. A score greater than 4 on the RACE scale is highly suggestive of an LVO, with a reported sensitivity of 85% and specificity of 69%. Using a tool like the RACE scale in the pre-hospital or initial emergency setting can help triage patients appropriately and activate the interventional team sooner. Learn more about how early identification of LVOs can significantly improve patient outcomes by reducing time-to-treatment.

 

What Are the Key Components of a Bedside Neurological Exam for Stroke?

Beyond standardized scales, a thorough bedside neurological exam is fundamental to understanding the full picture of a stroke patient's condition. This assessment should be systematic and tailored to the information gathered from the initial scales. Start with a chart review, paying close attention to any documented aphasia, as noted by organizations like the American Heart Association. When you approach the patient, assess their orientation to person, place, time, and situation. Can they follow commands? Is their gaze deviated? Observe for signs of neglect, such as ignoring one side of their body or environment. A comprehensive motor exam should assess both upper and lower extremities for strength, tone, and coordination. Don't forget to ask about sensory changes like numbness or tingling and to test for light touch discrimination. This detailed, hands-on assessment provides the qualitative context that a numerical score from a scale might miss. Think of it as building a detailed patient story, much like a journalist uses quotes to add depth to an article.

 

How Do You Assess Functional Outcomes After a Stroke?

The initial assessment focuses on the acute event, but a comprehensive stroke assessment template must also consider the patient's functional status and long-term prognosis. This is where functional and outcome assessment scales come into play. These tools are typically used in the post-acute phase, during rehabilitation, and in outpatient follow-up to track recovery and guide therapy. While not used in the hyperacute phase, understanding these scales provides a more holistic view of the patient's journey. They help answer the crucial question: "How will this stroke impact the patient's ability to perform their regular activities?" This part of the assessment is vital for discharge planning, setting realistic recovery goals, and communicating with patients and their families about what to expect.

 

Why is a Standardized Stroke Assessment Template Crucial for Your Workflow?

In the high-stakes environment of stroke care, standardization is key to efficiency, accuracy, and improved patient outcomes. A standardized stroke assessment template, incorporating the essential scales and examination components, ensures that every clinician performs a consistent and comprehensive evaluation. This reduces the risk of missed findings and provides a clear, longitudinal record of the patient's neurological status. For example, a consistent template allows a nurse on a night shift to quickly and accurately compare their assessment to the one performed in the emergency department hours earlier. Furthermore, structured data is easier to analyze for quality improvement and research. As healthcare technology evolves, consider how tools like AI scribes can integrate with these templates. An AI scribe can capture the nuances of your patient interaction and automatically populate the fields of your assessment template, freeing you to focus more on the patient and less on the keyboard. Explore how adopting a standardized template, potentially enhanced with AI, can revolutionize your stroke care workflow.

  

Comprehensive Stroke Assessment Template

This template is designed for clinical use to ensure a systematic and thorough evaluation of a suspected stroke patient, from pre-hospital screening to detailed inpatient assessment.

Patient Information:

• Patient Name: _________________________
• MRN: _________________________
• Date of Birth: _________________________
• Date of Assessment: //______
• Time of Assessment (24h): ________
• Last Known Well (Time): ________

 

Part 1: Pre-Hospital / ED Triage Screen (FAST Exam)

Circle the finding. Any "Yes" indicates a positive screen.

• F - Face: Ask patient to smile. Is one side of the face drooping? (Yes / No)
• A - Arms: Ask patient to raise both arms. Does one arm drift downward? (Yes / No)
• S - Speech: Ask patient to repeat a simple phrase. Is speech slurred or strange? (Yes / No)
• T - Time: If any sign is positive, note the time last known well and activate stroke protocol immediately.

 

Part 2: NIH Stroke Scale (NIHSS) Assessment

Score each item and calculate the total at the end.

 

NIHSS Item	Score	Instructions & Findings
1a. Level of Consciousness	0-3	0=Alert; 1=Drowsy; 2=Obtunded; 3=Comatose
1b. LOC Questions	0-2	(What month is it? How old are you?) 0=Both correct; 1=One correct; 2=None correct
1c. LOC Commands	0-2	(Open/close eyes; Grip/release hand) 0=Both correct; 1=One correct; 2=None correct
2. Best Gaze	0-2	0=Normal; 1=Partial gaze palsy; 2=Forced deviation
3. Visual Fields	0-3	0=No visual loss; 1=Partial hemianopia; 2=Complete hemianopia; 3=Bilateral hemianopia
4. Facial Palsy	0-3	0=Normal; 1=Minor paralysis; 2=Partial paralysis; 3=Complete paralysis
5a. Left Arm Motor	0-4	0=No drift; 1=Drift; 2=Some effort against gravity; 3=No effort against gravity; 4=No movement
5b. Right Arm Motor	0-4	0=No drift; 1=Drift; 2=Some effort against gravity; 3=No effort against gravity; 4=No movement
6a. Left Leg Motor	0-4	0=No drift; 1=Drift; 2=Some effort against gravity; 3=No effort against gravity; 4=No movement
6b. Right Leg Motor	0-4	0=No drift; 1=Drift; 2=Some effort against gravity; 3=No effort against gravity; 4=No movement
7. Limb Ataxia	0-2	(Finger-nose, heel-shin) 0=Absent; 1=Present in one limb; 2=Present in two limbs
8. Sensory	0-2	0=Normal; 1=Mild-to-moderate loss; 2=Severe loss
9. Best Language	0-3	0=Normal; 1=Mild-to-moderate aphasia; 2=Severe aphasia; 3=Mute/Global aphasia
10. Dysarthria	0-2	0=Normal articulation; 1=Mild-to-moderate slurring; 2=Unintelligible or worse
11. Extinction/Inattention	0-2	0=No neglect; 1=Partial neglect; 2=Complete neglect
TOTAL NIHSS SCORE		Sum of all scores (0-42)

 

 

Part 3: Supplementary Bedside Neurological Exam

Check if normal (N) or abnormal (A). Describe abnormal findings.

• Mental Status:
  • Orientation (Person, Place, Time, Situation): ________________
  • Attention/Concentration: ________________
• Cranial Nerves:
  • II (Visual Acuity): ________________
  • III, IV, VI (EOMs, Pupils): ________________
  • V (Facial Sensation): ________________
  • VII (Facial Strength - detailed): ________________
  • IX, X (Palate, Gag): ________________
  • XI (Shoulder Shrug): ________________
  • XII (Tongue Protrusion): ________________
• Motor Exam (Detailed):
  • Tone (Spastic, Flaccid, Normal): ________________
  • Pronator Drift: ________________
• Reflexes:
  • Biceps: L:___ R:___
  • Patellar: L:___ R:___
  • Babinski: L:___ R:___
• Cerebellar:
  • Gait/Stance (if able to assess): ________________ 

 

Part 4: Key Vitals & Labs

• Blood Pressure: ______ / ______ mmHg
• Heart Rate: ______ bpm
• O2 Saturation: ______ %
• Point-of-Care Glucose: ______ mg/dL

 

Part 5: Clinical Impression & Plan

• Summary of Findings:
• Suspected Stroke Location: 

• Plan / Next Steps:

  • Activate Stroke Code
  • STAT Head CT/CTA
  • Consider tPA
  • Consider Thrombectomy (LVO Screen)
  • Neurology Consult