Clinical Documentation Tip Sheets

TIA Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (See General) Focal neurologic signs Finding on brain imaging that requires inpatient care (eg, mass) Vascular imaging demonstrates extracranial carotid artery stenosis (50% to 99% stenosis) and ALL of the following: –Carotid artery stenosis is presumed etiology of TIA –Carotid intervention (carotid endarterectomy or carotid artery stenting) to be performed imminently (ie, during index hospitalization, no discharge to lower level of care with subsequent scheduling of elective procedure) Altered mental status that is severe or persistent Cardiac arrhythmias of immediate concern

CVA/STROKE

IInpatient admission is indicated for 1 or more of the following: National Institutes of Health Stroke Scale (NIHSS) score greater than 2 Evidence of hemorrhagic transformation Altered mental status that is severe or persistent

Dysphagia that warrants evaluation (eg, aspiration risk suspected) Significant arm or leg weakness (eg, limiting movement against gravity) Aphasia Gait impairment Finding on brain imaging that requires inpatient care (eg, mass, edema, large acute infarction) Clinical stability unclear (eg, recurrent or worsening findings) Acute ischemic stroke with clinical need for inpatient care or monitoring, as indicated by 1 or more of the following: –Hemodynamic instability –Cardiac arrhythmias of immediate concern –Thrombolysis or thrombectomy performed or planned

SEIZURE

IInpatient admission is indicated for 1 or more of the following: Hemodynamic instability (See General) Status epilepticus Brain disorder (eg, tumor, edema, trauma, hydrocephalus, encephalitis, meningitis) Etiology (eg, drug toxicity, withdrawal, nonadherence) Altered mental status that is severe or persistent Metabolic disorder (eg, hypoglycemia, electrolyte abnormality) that persists despite observation care Recurrent seizure and 1 or more of the following: –Recurrent seizure is of a different seizure type than previously known seizure disorder –Patient with baseline of infrequent seizures Medication initiation or adjustment that requires monitoring beyond observation care Increased intracranial pressure, cerebral edema, or hydrocephalus and monitoring needed