My Level of Understanding
0=I have limited understanding.
1=I’m able to state general concepts.
2=I can state details on the topic with some verbal cues from my nurse.
3=I can state details on the topic without help.
4=I know enough that I could problem solve issues if I needed to.
Stroke Patient Education Checklist
My Diagnosis is __________________________________
My doctor (s) ____________________________________
My Level of Understanding
Put date in each place
n/a 0 1 2 3 4 Ques/Comment
My diagnosis -
I am aware of the potential complications
I know the signs and symptoms of stroke.
I know when to call 911.
I have been given information on how to quit smoking. I
am aware of the risks of smoking.
All tests and procedures have been explained.
▪ CT/MRI scan
▪ Carotid ultrasound
▪ Blood tests (PT/PTT/INR)
▪ 12- lead EKG
▪ Chest X-ray
▪ Swallow study
▪ Other -
I have been taught about blood pressure. I know what
range my blood pressure should safely be in.
The diet I should eat has been explained to me.
I am aware of the options I have to reduce my cholesterol
level. I know what a lipid panel is and why it is important.
I have a plan for eating when I go home from the hospital.
I understand the importance of exercise in reducing my
stroke risk. I have an exercise plan.
Aspiration pneumonia has been explained to me. I know
how vital it is to swallow safely. I am aware of any
swallowing precautions I may have.
I know the reasons for testing my blood sugar. This
includes when, how often, and for how long.
I have been taught to use diabetic agents. This includes
oral medicines and/or insulin shots. (circle those that apply)
I know what exercises I can and should do, while in the
hospital and after discharge.
DVT prophylaxis/blood clot prevention has been explained
to me. I know why it is vital to keep doing ROM activities
as allowed by my doctor and to wear compression
stockings while in the hospital.
I have been given information about high fall risk
assessments and other safety issues.
I know how to use any adaptive devices I need.
(Commode, slings, walker, cane, extended grabber, padded
utensils, etc.). (circle those that apply)
I know that problems with bladder function can occur
because of stroke.
I know that having a stroke makes it more likely that I will
I am comfortable with the plan I have for my bathroom
I know what drugs I am taking and why. I know about
stopping any medicines or starting new ones. You may ask
for a list of medicines at any time.
I have been taught ways to manage my pain such as pain
medicines and alternative options.
I have discussed with pharmacy or the nurse about the
drugs I will need after discharge. We also talked about how
to get refills.
I have had a chance to talk about the feelings I have about
my stroke and its effects on my lifestyle and family.
I am aware of stroke support groups in my community.
I know when I am to have labs drawn after I leave the
I have been able to talk with a social worker or discharge
planner about my discharge plans.
I know how to contact any outpatient or Home Health
therapies I will need after discharge.
My nurse sat down with me and found out the answers to
all my questions before discharge.
I know who to call if I have questions after I am discharged
from the hospital.
Issues I need to discuss with my nurse/doctor are:
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