Preparing records for stroke rehabilitation in China: Imaging, medicines and function

A useful stroke rehabilitation record explains the event, the person's present abilities, and the risks that still need attention. A large collection of unlabelled test photographs may leave a receiving clinician unable to answer those questions. Before an assessment in China, organize a short referral summary, the original medical documents, and recent information about everyday function. The summary helps the team navigate; the underlying records allow it to check the evidence.

Key takeaways

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Identify the patient consistently and include age, stroke date, the main diagnosis, the purpose of the consultation, and an appropriate contact. Distinguish a first stroke from a recurrent event or a later episode of worsening old symptoms. If a date or conclusion is uncertain, say so. A clearly marked gap is safer than a confident detail reconstructed from memory.
Provide specialist swallowing reports and, if performed, videofluoroscopic or endoscopic assessment findings. Include the latest instructions about food texture, fluids, posture, supervision, medication route, and oral care. Weight change, nutritional support, and relevant chest infection episodes can help the receiving team understand ongoing risks. Saying that someone “can eat” does not explain which consistencies and conditions were assessed as suitable.[S7]
Once the Chinese team has reviewed the information, ask which missing documents would materially change its judgment and which investigations can be decided after examination. An acknowledgment of receipt is not confirmation of a completed medical review, an agreed rehabilitation duration, or a predicted outcome. If the evidence supports only an initial consultation, keep that limitation visible in the travel plan.

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Full guide

Put the reason for referral on the first page

Identify the patient consistently and include age, stroke date, the main diagnosis, the purpose of the consultation, and an appropriate contact. Distinguish a first stroke from a recurrent event or a later episode of worsening old symptoms. If a date or conclusion is uncertain, say so. A clearly marked gap is safer than a confident detail reconstructed from memory.

Describe the most important current activity problems. For example, two people may be needed for a bed-to-chair transfer; walking indoors may require a frame and supervision; comprehension may be better than spoken expression; or feeding may still follow a specialist swallowing plan. Add the patient's own priority. This helps a Chinese receiving service decide which professional should first review the case and what kind of assessment is needed.[S3]

The summary should not try to replace a discharge report or assign a new diagnosis. Its purpose is to explain why another opinion is being requested and guide the reader to relevant documents. If the family and patient have different priorities, record both rather than silently selecting one.

Preserve the sequence of the stroke and hospital care

Acute admission records, discharge summaries, procedure reports, and important consultation findings help explain the diagnosis and subsequent restrictions. Where thrombolysis, endovascular treatment, decompressive surgery, or another procedure was performed, obtain the corresponding record if available. The receiving team needs to know what happened, when it happened, and whether there were complications or outstanding follow-up instructions.[S23][S36]

For several admissions, make a dated index explaining the reason for each stay and the main change. Avoid rearranging everything into categories in a way that loses chronology. If a report was amended, identify the final version and preserve the information about correction. A result that seems repetitive may still show a trend relevant to treatment.

Family notes can help fill in practical context, but distinguish them from the medical record. Write “family observed” where appropriate, and attach the original clinical conclusion rather than replacing it with an interpretation. This is particularly helpful when symptoms changed after discharge and the explanation is still being investigated.

Request complete imaging as well as the report

The radiology report and the image files serve different purposes. The report records an interpretation; complete original images allow the receiving clinicians to review the study in relation to their own clinical questions. Ask the original institution how to obtain readable copies of relevant brain and vascular examinations and the formal reports. Check the Chinese hospital's accepted formats and transfer method before sending them.[S23]

Label each study with the date and examination type, and confirm that the patient identifier matches. A few compressed screenshots chosen because they look dramatic cannot represent a complete study. Do not arrange another scan solely to make a referral folder look comprehensive. Whether updated imaging is needed depends on the clinical question, changes in symptoms, and the quality and availability of previous studies.

If new symptoms suggest another stroke, seek emergency care rather than waiting to finish a document package or obtain an overseas opinion.[S21] Conversely, an abnormality on an old scan does not establish that a new event is occurring. Imaging findings require interpretation with the timeline and examination. They also cannot alone show how well a person now communicates, walks, or manages eating.[S3][S30]

Connect the suspected cause with secondary prevention

Include the treating team's assessment of the stroke mechanism and investigations already performed. Depending on the case, vascular studies, electrocardiography or rhythm monitoring, cardiac investigations, and relevant laboratory results may affect prevention. If the mechanism remains uncertain, identify what is still under review and the proposed next step. A normal brief test should not be interpreted by the family as closing an investigation that the clinician still considers necessary.[S23]

For antiplatelet or anticoagulant therapy, provide the reason for treatment when documented, the start date, and any intended review or change. These medicines are used in different clinical circumstances. Important bleeding history and relevant contraindications should travel with the prescription information. Do not stop treatment for the purpose of an assessment or substitute one category for another without medical advice.[S11][S12]

An old discharge list is evidence of what was prescribed at that time, not proof of the current regimen. Keep it, but make the current medication list separately and identify later changes. This allows the next clinician to understand the sequence instead of guessing which of several inconsistent lists is accurate.

Make the medication list describe actual use

Record the generic and brand names, strength, amount per dose, timing, route, start date, and prescribing clinician where possible. Include nonprescription products, supplements, and Chinese herbal products actually being used. Put discontinued medicines in a separate section with the stop date and reason if known. A clear photograph of the packaging and prescription can help verify an uncertain name; tablet color alone cannot reliably identify a medicine.

For someone with dysphagia or tube feeding, explain how medicines are actually administered. Do not assume a tablet can be crushed or a formulation replaced. Record allergies with the reaction, distinguishing them from nausea, sleepiness, or another intolerance. If dizziness, falls, or marked drowsiness developed around a medication change, describe the timing and circumstances so that a clinician can assess the relationship.[S7][S18]

Bring relevant monitoring results requested by the current team, such as renal or liver tests when they affect treatment. There is no need to order every available blood test to create a complete-looking folder. The useful handover identifies which results already exist, which are pending, and who is responsible for acting on them.

Keep scale versions and assessment conditions

A score without the scale name, version, and date may be misleading. The Fugl-Meyer Assessment includes different domains, while Barthel measures also have different versions. Retain the actual assessment sheet or report, subscale scores, date, and examiner's comments. An upper-limb motor score should not be presented as a whole-body recovery score, and a daily-activity score is not a percentage of brain repair.[S25][S26]

Record whether a brace or walking aid was used, how much assistance was provided, and whether pain, fatigue, comprehension, or communication affected testing. When comparing two assessments, note different conditions rather than selecting the highest number as the current level. For balance and walking, documented falls and everyday performance remain important even when a formal score has improved.[S20][S28]

A short video may help an intake team understand a familiar movement. Obtain the person's agreement and use the receiving service's approved channel. Show an activity already permitted in the person's plan, with the usual aid and assistance visible. Do not ask for an unfamiliar unsupported stand or conceal the helper in order to demonstrate potential. Video is supplementary information, not a replacement for examination.

Highlight swallowing and nutrition information

Provide specialist swallowing reports and, if performed, videofluoroscopic or endoscopic assessment findings. Include the latest instructions about food texture, fluids, posture, supervision, medication route, and oral care. Weight change, nutritional support, and relevant chest infection episodes can help the receiving team understand ongoing risks. Saying that someone “can eat” does not explain which consistencies and conditions were assessed as suitable.[S7]

Identify the date of the current recommendation and the clinician or service that made it. If the family has found the plan difficult to implement, say where the difficulty lies rather than replacing it with an informal description of unrestricted eating. The new team needs to know both the recommendation and what is actually happening at home.

Explain communication and cognitive testing fairly

Language therapy notes should identify the person's usual languages, comprehension and expression difficulties, useful communication methods, and reading or writing abilities. For cognitive testing, record the language used and relevant educational, hearing, visual, and aphasia-related factors. An unanswered spoken question can have several explanations; cross-language care makes this background particularly important.[S8][S17]

If a communication aid works well, include a copy or description and explain how the patient signals agreement, refusal, pain, and uncertainty. This information helps the Chinese team speak directly with the patient. It also reduces the chance that a translation difficulty is mistaken for a change in cognition or that a family member's account substitutes for the patient's own view.

Describe previous therapy by task and response

A list consisting only of “physiotherapy,” “acupuncture,” or “robot training” says little about what was practiced. Where records are available, include the activity target, treatment content, reassessment findings, and reasons for stopping or changing an intervention. Examples include transfer practice, reaching and grasping, walking endurance, or communication strategies. Record troublesome fatigue or discomfort as well as perceived gains.[S5][S6]

For injections, operations, or an implanted device, attach the procedure record, product information, and subsequent restrictions. A generic description may hide differences relevant to the next assessment. Device compatibility and the safety of a proposed investigation must be checked for the particular patient and product; a family should not infer permission for MRI or stimulation from an advertisement for a similar device.[S27]

The record should show what the patient can currently reproduce, not only the best result seen at some point during treatment. A previous successful movement may still matter, but its date, conditions, and subsequent course help clinicians understand why performance is different now.

Include the home that the plan must work in

Describe the long-term home, stairs, bathroom access, available helpers, local rehabilitation services, and the clinician expected to continue prescriptions and medical review after return. A transfer learned in hospital can become difficult with a lower bed or a narrow doorway. Relevant measurements or a simple layout can be more useful than the statement that a relative will provide care.[S19]

Add the person's previous family, educational, or work roles and the activities they most want to resume. Persistent low mood, sleep difficulty, and fatigue are also rehabilitation concerns. A patient who communicates slowly may need extra time to explain these problems. The record should not focus so exclusively on walking that important barriers to participation disappear.[S9][S18]

Keep translations and versions traceable

Ask the receiving institution which languages and document formats it accepts. Keep the original beside the translation and check names, dates, units, medicine details, and left-versus-right references carefully. If a word cannot be read or a conclusion is uncertain, mark it for verification. Do not translate a provisional diagnosis as established or expand “no definite abnormality identified” into a claim that every relevant result was normal.

Use the hospital's confirmed submission channel and verify who will receive the documents. The patient should understand what information is being shared and for what purpose. Keep a copy and an index showing the most recent update. If a medicine changes, another admission occurs, or function changes substantially while waiting for review, provide the update so that arrangements are not based on an obsolete summary.

Where several relatives are helping, nominate someone to maintain the current version. This is a practical way to reduce inconsistent medication lists or differently dated descriptions. The patient and treating team should still be able to correct that record. Administrative convenience should not turn an uncertain family recollection into a fixed clinical fact.

Ask what remains necessary after submission

Once the Chinese team has reviewed the information, ask which missing documents would materially change its judgment and which investigations can be decided after examination. An acknowledgment of receipt is not confirmation of a completed medical review, an agreed rehabilitation duration, or a predicted outcome. If the evidence supports only an initial consultation, keep that limitation visible in the travel plan.

A well-organized record allows the reader to understand the purpose quickly and trace important statements to the original evidence. Patients do not need to interpret every abnormality themselves. Accurate chronology, current medication, and realistic functional information give the Chinese clinicians and the original treating team a common starting point for care.