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Table 1 An overview of the information documented in Anna’s electronic health record

From: Accessing and sharing health information for post-discharge stroke care through a national health information exchange platform - a case study

At the hospital At the rehab clinic (two months) At home with the neurology team
- Admission cause: Mild nausea, paralysis of right side, slurs
- Social: lives with husband and two children
- Earlier disease: Hypertension and dyslipidaemia. Has contact with healthcare
- Tobacco: not tested
- Alcohol: not tested
- Driving: has a driving license
- Current drugs: Simvastain 20 mg, Enalapril 10 mg
- Investigations: Computer tomography, bleeding omitted
- Assessment: Reduced function in the right side, arm and ben, Aphasia, hard to understand. Patient is concerned about her situation and how it will affect her children.
- Action: Blood thinning and clot-dissolving medicine.
- Computed tomography, bleeding excluded.
- Physiotherapist: The patient feels slightly sick for a jog and becoming paralyzed in the right side. The patient cannot walk without support. Gets up with easy-care support.
- Occupational: MOCA test. Patient does not know what day it is and not where she is.
- Speech therapist: Boston Naming Test - have great difficulty naming several of the pictures. The patient has a good understanding of the situation, but it is difficult to follow long complicated instructions.
- The patient’s children have also talked to the counsellor.
- Speech therapist, Physiotherapist, and occupational therapist contact
- Continued counsellor contact
- Doctors. The patient is discharged from the clinic. She has improved during the hospital stay. Referral to a rehabilitation clinic.
- Admission Cause: Weakness in the right arm and leg. Aphasia. Do not remember everything that happened in the Emergency Department.
- Occupational therapy - Cognitive screening, arm and hand exercise
- Speech therapy language training and literacy classes
- Neuropsychologist - investigation. The patient gets tired quickly, can only read short moments.
- Physical therapy - The patient has constant pain on right side and gets hurt by the slightest movement. Despite this patient practices with the physiotherapist. She also exercises three hours / day. She is informed that even everyday tasks are training.
- Occupational therapy - kitchen training, as well as shopping.
- Speech Pathology - language training as well as reading and writing exercises.
- Summary of neurology team’s efforts. The patient now has a diary, which she can enter the date of exercise and health visit. The patient gets still tired easily and must therefore rest frequently.
- It is important for her to plan their activities so that she can manage her daily work.
- The patient can now walk longer distances and can use her right hand. She has improved linguistically - may now take part in conversations with several people. She also reads and writes better, but not enough for her to start working. Fatigue also prevents her from long working days.
- She is concerned about their hidden disabilities such as brain fatigue and personality change.
- Patient is considering why she was diagnosed with stroke.
- Neurology team provides continuous information about stroke and its consequences. The patient also receives explanation of what and why she should train and motivate her to continue training. Patient is also encouraged to re-connect with the family doctor. Neurology team is also in contact with family doctor during the treatment period.
- Patient is also encouraged to contact the patient associations who are in the locality and informed of SMIL (Stroke in the middle of life). SMIL also has a Facebook group where you can talk with others who have had a stroke. The patient is also informed that she can through the family doctor apply for specialist planned rehabilitation.