The NIH Stroke Scale scores 15 items of the neurological exam, from alertness to neglect. Its total, from 0 to 42, measures how severe a stroke is and tracks change over the first hours and days. Score each item to get the total, see what each band means, and record the result with its times in the free template.
NIHSS result template
FreeNIHSS RESULT Date: [Date] Patient: [Name or ID, age] Setting: [Prehospital, emergency department, telestroke, stroke unit, or ward] Reason: [Stroke alert, after thrombolysis, after thrombectomy, change in condition, 24 hours, or discharge] TIMES Last known well: [Date and time, and who gave it] Symptoms found: [Time and by whom] Assessed: [Time the scale was given] SCORES 1a Level of consciousness: [0 to 3] 1b LOC questions: [0 to 2] 1c LOC commands: [0 to 2] 2 Best gaze: [0 to 2] 3 Visual: [0 to 3] 4 Facial palsy: [0 to 3] 5a Left arm: [0 to 4, or UN] 5b Right arm: [0 to 4, or UN] 6a Left leg: [0 to 4, or UN] 6b Right leg: [0 to 4, or UN] 7 Limb ataxia: [0 to 2, or UN] 8 Sensory: [0 to 2] 9 Best language: [0 to 3] 10 Dysarthria: [0 to 2, or UN] 11 Extinction and inattention: [0 to 2] Total: [0 to 42] Band: [No stroke symptoms, minor, moderate, moderate to severe, or severe] Untestable items: [Item and reason, or none] Barriers: [Interpreter, intubation, sedation, hearing or vision loss, or none] REPEAT SCORES Repeat: [Time, total, and the items that changed] Repeat: [Time, total, and the items that changed] Change from baseline: [Points better or worse; stroke team called if worse] CLINICAL PICTURE Findings outside the scale: [Glucose, blood pressure, rhythm, gait, swallow] Imaging: [CT, CT angiography, perfusion or MRI: time and findings] Disabling deficit: [Yes or no, and which deficit] Impression: [Stroke type, side, and vessel] PLAN Thrombolysis: [Drug, dose, and time; or not given, and why] Thrombectomy: [Referred, done with time and result, or not indicated, and why] Next NIHSS: [Time or interval] Assessed by: [Name, credentials, NIHSS certification date]
Every item as published. The total and what it means update with each answer; nothing you choose leaves this page.
Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).
Level of consciousness
Eyes and face
Motor
Coordination and sensation
Language, speech, and attention
Use it for
Fix the times first: when the patient was last known well, and when you give the scale. Check the glucose, since a low sugar can mimic a stroke.
Avoid: Holding up the CT to perfect the exam. In a stroke alert, score quickly and in order; trained examiners take about 5 to 10 minutes.
Give the items in the order listed and record each score as soon as you’ve tested it.
Avoid: Going back to change an earlier score after a later item. Each score stands as recorded.
A handful of rules settle most disputed scores.
Avoid: Scoring UN for weakness, sedation, or poor effort. UN is only for the physical reasons the form names.
The total grades severity; the item scores show what kind of deficit it is.
Avoid: Reading a low total as a small stroke. A total of 3 from severe aphasia can end someone’s working life.
Repeat the NIHSS after treatment, at set times, and whenever the patient changes.
Avoid: Reading a 1-point change between two examiners as a real change. Ataxia, facial palsy, and dysarthria are the items examiners most often score differently.
Each one follows the recording template. Use them to judge how much to write.
Emergency department, stroke alert, scored by the stroke nurse on arrival
Last known well 07:40, per her husband: normal at breakfast. Found at 08:15 unable to lift her left arm. Arrived by ambulance 08:52. NIHSS given 08:58.
1a 0, 1b 0, 1c 0, gaze 1, visual 2, face 2, left arm 3, right arm 0, left leg 2, right leg 0, ataxia 0, sensory 1, language 0, dysarthria 1, extinction 2. Total 14, moderate stroke. No untestable items.
09:45, after tenecteplase: 13, left arm better at 2. 11:05, after thrombectomy: 7, gaze now normal. 24 hours: 4, with face 1, left arm 1, left leg 1, and extinction 1.
72-year-old woman with high blood pressure, on no blood thinners. Right gaze deviation overcome by head turning, complete left hemianopia, and she didn’t recognize her left hand as her own. Glucose normal; blood pressure 182/94. CT 09:06: no bleed, ASPECTS 9. CT angiography: right M1 occlusion. Impression: right middle cerebral artery stroke from a large vessel occlusion.
Tenecteplase 17 mg, 0.25 mg/kg, at 09:19: door to needle 27 minutes. To angiography for thrombectomy; reperfusion eTICI 2c at 10:41. Admitted to the stroke unit, neuro checks every 15 minutes for 2 hours and then by protocol, swallow screen before anything by mouth.
Community hospital emergency department, telestroke video consult with the stroke neurologist
Last known well 13:00, speaking normally in a staff meeting. Coworkers noticed at 13:20 that he couldn’t find his words. Arrived 13:48. NIHSS given over video at 14:02, with the emergency nurse at the bedside.
1a 0, 1b 1: gave his age, not the month. 1c 0. Gaze, visual, face, all four limbs, ataxia, and sensory 0. Language 2: fragmentary speech, and most naming sheet items not identifiable from his answers. Dysarthria 0, extinction 0. Total 3, minor stroke.
15:10, after tenecteplase: 2, language better at 1. 24 hours: 1, with mild word-finding pauses only.
58-year-old high school teacher with type 2 diabetes. Severe expressive aphasia; follows commands; no weakness, field loss, or neglect. Glucose normal. CT 14:10: no bleed. CT angiography: no large vessel occlusion. Impression: left hemisphere ischemic stroke with isolated severe aphasia, a disabling deficit despite a total of 3: he couldn’t speak in sentences, read aloud, or teach.
Benefits and risks discussed with his wife, and with him using yes and no questions; they chose treatment. Tenecteplase 21 mg, 0.25 mg/kg, at 14:27. Transferred to the regional stroke unit for MRI, heart monitoring, and an echocardiogram. Speech-language assessment the next day.
Severe aphasia, complete hemianopia, or neglect can be disabling with a total of 2 or 3. Decide on disability from the deficit, not the number.
On item 1b, an aphasic patient who doesn’t understand the questions scores 2; a patient who can’t answer because of intubation or a language barrier scores 1. Use an interpreter before you score.
Ataxia counts only out of proportion to weakness. A paralyzed arm scores 0 on item 7, not 2.
Hinting at the month, or giving a second try on a command, makes the patient look better than they are and breaks the comparison with later scores. Score the first attempt and move on.
A total with no time beside it can’t be compared with the next one, and the last known well time decides what treatment is possible. Record both every time.
Vero Scribe records the NIHSS result in your template from the visit, with the patient’s consent, or from your dictation: the times, each item score, the total, and the repeat scores. You review and edit every line, then copy it into your record. Vero works in 60+ languages.
Give the 15 items in order and score each one as you test it: level of consciousness, the two questions and two commands, gaze, visual fields, facial palsy, each arm and leg, limb ataxia, sensation, language, dysarthria, and extinction. Add them for a total from 0 to 42. An item scored UN, untestable, adds nothing; record the reason.
Higher is more severe. A common grading is 0 no stroke symptoms, 1 to 4 minor stroke, 5 to 15 moderate, 16 to 20 moderate to severe, and 21 to 42 severe. The total doesn’t show the kind of deficit, so read the item scores too: a 3 from severe aphasia can be more disabling than a 6 from mild weakness.
Thrombolysis has no minimum score. It’s considered within the time window when the deficit is disabling, whatever the total; a minor stroke with no disabling deficit is usually treated with antiplatelets instead. Thrombectomy for a large vessel occlusion usually needs a score of 6 or more, along with imaging and timing criteria. Your stroke protocol sets the exact rules.
Yes. The scale doesn’t test gait, truncal balance, vertigo, or swallowing, so a stroke in the cerebellum or brainstem can score 0 or 1. Examine gait and the rest of the neurological exam, and image when the story fits a stroke.
The Glasgow Coma Scale measures level of consciousness, from 3 to 15, after head injury and in anyone less alert. The NIHSS measures the focal deficits of a stroke, from 0 to 42. A patient with a large right-sided stroke can have a Glasgow score of 15 and an NIHSS in the teens.
Any trained clinician: emergency physicians, neurologists, stroke nurses, and others on stroke teams. Paramedics usually use shorter stroke scales in the field, and some, such as RACE and LAMS, are built from NIHSS items to spot a large vessel occlusion.
Through an online course with video patients and a scored test, such as the American Heart Association’s NIH Stroke Scale course, which NINDS links to from its page. Most stroke programs ask staff to recertify every one to two years.
Yes. It’s in the public domain, and the official version, with the picture, naming sheet, sentences, and word list for items 9 and 10, is a free PDF on the NINDS site. Certification courses set their own terms. The recording template on this page is free to copy or download.
Eye, verbal, and motor responses: level of consciousness, scored 3 to 15.
The prehospital record that hands over the last known well time and the field stroke scale.
Notes for stroke follow-up and the rest of neurology, written from the visit.
Notes for the emergency department, from the stroke alert to disposition.
Every tool, by area, with what its scores mean.
Vero records scores, findings, and plans in the templates you choose, so you review instead of type.
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