UMEM Educational Pearls

Title: Acute Stroke Treatment Documentation

Category: Neurology

Keywords: stroke, tpa, ischemic stroke, acute stroke (PubMed Search)

Posted: 12/10/2008 by Aisha Liferidge, MD (Updated: 11/21/2024)
Click here to contact Aisha Liferidge, MD

Important things to document in acute ischemic stroke cases from a medicolegal aspect:

-- time of onset
-- time of diagnosis
-- why tPA given or not given (the longer note for NOT giving it; 90% of related litigation cases based on NOT giving tPA.)
-- date and time on each side of note of every page
-- make it legible