UAMS Institute for Digital Health & Innovation Stroke Program Data Submission

Date *

Site *

Submitted by: *

Email *

Reporting Month *

How many Acute Ischemic Stroke (AIS) patients were seen in your facility? *

How many of those AIS patients seen in your facility DID NOT receive an IDHI Stroke Program telestroke consult? *

Reasons IDHI Stroke Program was not contacted for AIS Patients Within Your Facility Only:

Choose one category per patient

Number of patients with symptoms > 4.5 hours: *

Number of patients who used newer anticoagulants (Xarelto, Pradaxa, Eliquis) in the last 48 hours: *

Number of patients with a history of intracranial hemorrhage: *

Number of patients presenting with abnormal labs: *

Number of patients with either an intracranial neoplasm, AVM, or untreated aneurysm > 10mm: *

Number of patients showing minor deficits/symptoms resolved: *

Number of patients IDHI Stroke Program DID NOT consult with for any other reason not listed above:

Number of AIS patients that received a in-house neurology consultation?

Please specify other reasons not listed above: *

Total Number of Patients IDHI Stroke Program DID NOT consult for: *

Note: This number should match the number above for those AIS patients in your facility who DID NOT receive an IDHI Stroke Program telestroke consult.

Stroke Survivor(s):

Note: Stroke Survivors appear in annual reports and at conferences.

Please check the box below if any of your patients could be considered a Stroke Program Stroke Survivor?

Possible Stroke Survivor

Note:We will contact you for more information if the box is checked.

Community Education

Active Events

Active Event Name *

Event Location *

Address *

ZIP / Postal Code

Education Method *

Activity Engagement Level *

About how many people were educated face to face? *

Another Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face? *

Is there a 3rd Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there a 4th Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face? *

Is there a 5th Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there a 6th Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there a 7th Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there an 8th Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face?

Is there a 9th Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face? *

Is there a 10th Active Event?

Yes

Active Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Activity Engagement Level

About how many people were educated face to face? *

Community Education

Passive Events

Passive Event Name *

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached: *

Another Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 3rd Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 4th Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 5th Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 6th Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 7th Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there an 8th Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 9th Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Education Method

Number of Participants Reached:

Is there a 10th Passive Event?

Yes

Passive Event Name

Event Location

Address *

ZIP / Postal Code

Number of Participants Reached:

Education Method

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UAMS Institute for Digital Health & Innovation Stroke Program Data Submission

IDHI Stroke Program Data Submission Form

Reasons IDHI Stroke Program was not contacted for AIS Patients Within Your Facility Only:

Stroke Survivor(s):

Community Education

Community Education

Calendar

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