Table 4 Information documented in the emergency department (ED)
Demographic and organizational patient data | Information documented by admitting medical staff | Information documented by ED neurologist |
|---|---|---|
- name | - current complaints | - general evaluation incl. neurological examination |
- date of birth | - description of symptoms | - tentative diagnosis (ICD-10-Code) |
- sex | - medical history | - indicated diagnostics (e.g., imaging) and results |
- case ID | - risk factors (e.g., smoking behavior, hypertension, diabetes mellitus) | - medication administered |
- treating department (e.g., emergency department) | - vital signs | - recommendations, for example admission to stroke unit |
- date and time (d&t) of hospital admission | - concomitant medication | - NIHSS incl. single sub-points** |
- d&t of first contact with physician | - leading symptoms (selection via radio button): | - information about stroke/TIA (selection via radio button):** |
- means of patient transport to hospital (e.g., ambulance) | - no information | - no stroke or TIA |
- stomach ache | - stroke with alarm*** | |
- chest ache | - stroke without alarm | |
- dyspnea | - TIA | |
- stroke/transient ischemic attack (TIA)* | - d&t alarm** | |
- headache | - d&t symptom onset or d&t last seen well** | |
- none of these symptoms | - information about thrombolysis:** | |
- yes/no if yes: d&t start of thrombolysis; if no: reason why not: (textfield) |