CVA Stroke

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Trace DC84-5

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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4. Abnormal findings — the necessity chain

Finding → severity → comparison → risk → intervention → notification (provider + representative) → orders → response → reassessment.

Model abnormal 1

Recurrent or worsening stroke: a new or worsening focal deficit (a new weakness, speech change, or facial droop) different from the documented trajectory — a positive BE-FAST screen concerning for a recurrent stroke. The stroke/transfer pathway activated immediately, the provider and responsible party notified, time last-known-well documented, vitals and glucose obtained, and the resident kept NPO pending evaluation. Reassessment on return with an MDS/CAA update. Skilled recognition required, as a recurrent stroke is time-critical — especially with the antithrombotic status. (The exam routes to the Neurological reference.)

Model abnormal 2

Post-stroke complication: new coughing and a wet voice with meals with a low-grade fever (aspiration), or new unilateral calf swelling and pain (DVT), or a marked drop in mood and engagement stalling therapy (post-stroke depression). The relevant finding assessed, the provider (and speech therapy for swallowing) notified, orders received (a swallow re-evaluation and diet change, a Doppler, or mood management), the plan revised, and the resident monitored. Will reassess; supports the Section update. Skilled recognition and management required. (Aspiration routes to Taste/Swallowing; DVT to Peripheral Vascular; mood to Psychosocial.)

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