NIHSS 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]