Name: Acute stroke — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Stroke care is a race against the clock, and the chart is the stopwatch. The defensible record nails the last-known-well time, the NIHSS, the hemorrhage read, and the reperfusion decision — including the risk/benefit conversation — because in stroke, failure to treat draws more suits than the treatment's complications.

01What's at stake

The dominant medicolegal lesson is counterintuitive: far more lawsuits are filed against emergency physicians for failure to give reperfusion therapy than for its hemorrhagic complications, and protocol deviations are tied to worse outcomes. The best defense is a documented, protocol-driven assessment: onset time, deficit severity, hemorrhage exclusion, eligibility, and a shared decision.

02Can't-miss & the forks

Large-vessel occlusion — severe deficits; CTA identifies it and opens the door to thrombectomy.
Hemorrhage — the non-contrast CT's first job is the ischemic-vs-hemorrhagic fork.
Posterior circulation — vertigo/diplopia/ataxia easily dismissed; "when in doubt, consider posterior ischemia."
Cervical artery dissection — headache/neck pain ± deficit, spontaneous or post-trauma.
Mimics — hypoglycemia and seizure/Todd paralysis first; don't mislabel a stroke as conversion/psychiatric.

03History & exam — the clock and the score

Last-known-well — the single most important time; for wake-up strokes, the time last seen normal. It drives every window. → eligibility
Glucose first — exclude hypoglycemia before calling it a stroke.
NIHSS — document the score for severity, eligibility, and prognosis; remember it under-weights posterior-circulation findings, so a low NIHSS doesn't exclude a dangerous posterior stroke.
A thorough, expert neuro exam — alterations from baseline deserve careful consideration, not anchoring.

Skip the typing

Run the case in the Stroke / focal deficit Workup — it records last-known-well, glucose, the NIHSS/neuro exam, stroke-pathway activation, and BP management, and assembles an MDM that documents the time-critical decisions.

04Imaging & reperfusion

Non-contrast CT immediately to exclude hemorrhage; early ischemic signs (hyperdense vessel, insular ribbon loss) are subtle and insensitive.
CT angiography for large-vessel occlusion (and dissection); CT perfusion / MRI help select extended-window and wake-up patients.
IV thrombolysis (0.9 mg/kg alteplase) within the established window after weighing inclusions/exclusions and treating blood pressure to the protocol target; document the risk/benefit discussion.
Endovascular thrombectomy for large-vessel occlusion — windows have expanded substantially since the trials in the source issue, so apply current AHA/ASA guidance and your local protocol; if your site can't offer it, consider transfer while the patient remains eligible.

05What to document

▼ weak

"Weakness, CT negative. Neuro consulted. Admitted."

▲ defensible

"Right hemiparesis and aphasia; last-known-well 0840 (62 min prior). Glucose 108 — hypoglycemia excluded. NIHSS 11. Stroke pathway activated; non-contrast CT without hemorrhage, CTA with left MCA occlusion. Thrombolytic inclusions/exclusions reviewed and eligibility met; BP managed to protocol target; risks/benefits discussed with patient and family, who agreed. Neuro-interventional consulted for thrombectomy; door-to-CT and door-to-needle times recorded. Posterior circulation and dissection considered."

06Where charts fail

No precise last-known-well — the time the whole pathway hinges on.
Not documenting the glucose, or the hemorrhage read, before reperfusion.
Dismissing isolated vertigo/ataxia without considering posterior circulation.
Not documenting the reperfusion eligibility assessment and the risk/benefit conversation — the failure-to-treat exposure.
Not considering transfer when the patient is still within an endovascular window.

07Sources

Thurman RJ, Jauch EC, Panagos PD, et al. Four evolving strategies in the emergent treatment of acute ischemic stroke. Emergency Medicine Practice (EB Medicine). 2012;14(7).
NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-1587.
Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke (ECASS III). N Engl J Med. 2008;359(13):1317-1329.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: AHA/ASA. Stroke. 2019;50(12):e344-e418.
Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch (DAWN). N Engl J Med. 2018;378(1):11-21.

Note: reperfusion windows and selection have evolved beyond the source issue — always apply current AHA/ASA guidance and local protocol.

Acute stroke: documentation that holds up