NIH Stroke Scale

I know that clinicians' (nurses, etc) documentation can be used for coding for certain things like SDOH, pressure ulcer stage, and NIH stroke scale.

But what do you do when physician documentation conflicts with nursing documentation?

We had a patient whom the ER doctor stated the NIH stroke scale score was 0, and at about the same time nursing documentation recorded a stroke scale of 2.

My gut instinct would be that a doctor's documentation should trump nursing.



  • Hi Carol,

    The patient could be at different scores at two points in time, however, I would refer back to the ED doc and query as a discrepancy or if the patient is admitted, refer to the attending to resolve the discrepancy and have it documented or amended.

    Hope that helps. Deanne

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