The availability and reliability of information on the premorbid functional status of stroke patients in hospital

Abstract

In order to predict outcome after a stroke and set realistic targets for rehabilitation, it is essential to have reliable information on the patient's premorbid functional status. We assessed the availability of information on premorbid continence, mobility and mental status by examining the medical and nursing notes, one week after admission to a teaching hospital, of 164 stroke patients. Simple rating scales were used and results compared to information obtained from patients' relatives. Useful information on previous mobility was obtained from the notes in 58% of cases, on continence in 47%, and mental state in 44%. Although agreement between medical and nursing notes was reasonable (possibly due to sharing of information), agreement with the same information obtained from relatives was very poor. Information on the premorbid functional status of stroke patients is often not available in hospital notes, and when recorded is often inaccurate. Such data should be routinely obtained using standardized measures.