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.
: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: