(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.
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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
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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
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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 --------------------------------------
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Copyright Bradley Whale 2011. No unauthorised reproductions. www.bradleywhale.co.uk Ankylosing Spondylitis What is ankylosing spondylitis? Ankylosing spondylitis is a form of chronic inflammation of the spine and the sacroiliac joints. The sacroiliac joints are located in the low back where the sacrum (the bone directly above the tailbone) meets the iliac bones (bones on either
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