Cerebrovascular Accident (CVA) and Transient Ischemic Attack (TIA) [Documentation Suggestions]

  • Describe clinical signs and symptoms (e.g., weakness, dysphasia, severe headache, etc.). All signs and symptoms disappearing within 24 hours may be indicative of TIA rather than CVA.
  • Note time of first symptom onset.
  • Document work-up (e.g., head CT scan, brain MRI, carotid ultrasound, etc.).
  • Document treatment (e.g., antithrombotic, TPA, physical therapy, etc.).
  • Note rationale when TPA contraindicated.
  • List antithrombotic prescribed at discharge.
  • Note any patient education (given to patient, family, or caregiver) regarding antithrombotic therapy.

Additional notes:



Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: http://www.hce.org/medicare/mcareHPMP.html 7/7/03)