Stroke Thrombolysis Audit Form
Audit form for reviewing and assessing thrombolysis cases in acute stroke care. Please complete all relevant fields for each case.
Case Audit ID (de-identified)
*
Date and Time of Stroke Symptom Onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time of Hospital Arrival
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time of Thrombolysis Administration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
NIHSS Score on Admission
*
Eligibility for Thrombolysis
*
Eligible and treated
Eligible but not treated
Not eligible
If not eligible or not treated, specify reason
Please Select
Late presentation
Contraindications
Patient refusal
Rapid improvement
Other (specify in comments)
Thrombolytic Agent Used
*
Alteplase (tPA)
Tenecteplase
Other
Complications During or After Thrombolysis
*
None
Symptomatic intracranial hemorrhage
Angioedema
Other (specify in comments)
Outcome at 24 Hours (Modified Rankin Scale)
*
0 - No symptoms
1 - No significant disability
2 - Slight disability
3 - Moderate disability
4 - Moderately severe disability
5 - Severe disability
6 - Death
Submit Audit
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