The Official CVA SOAP Note Guide With Examples

When someone walks into your emergency department with stroke symptoms, the clock starts ticking immediately.

You have minutes to assess, document, and decide on potentially life-saving interventions like tPA.

Yet somehow, you're also expected to create flawless documentation that justifies every decision you made under extreme time pressure.

I've watched emergency physicians, neurologists, and hospitalists struggle with this impossible balance.

They provide excellent stroke care but end up in documentation battles with insurance companies months later over tPA administration, admission decisions, or imaging orders.

The problem is that CVA documentation isn't just medical record-keeping—it's legal protection, quality metric reporting, and insurance justification all rolled into one high-stakes note.

Miss documenting the NIHSS score, forget to record the time symptoms began, or fail to document why you chose one intervention over another, and you're vulnerable to denials, lawsuits, and quality measure failures.

I built SOAP Notes Doctor to handle this complexity, but today I'm going to show you exactly what makes a CVA note defensible, regardless of how you document.

Why CVA Documentation Is Higher Stakes Than Almost Anything Else

Stroke documentation carries unique pressures that most other medical notes don't face.

Time windows matter legally: tPA has a 4.5-hour window. Thrombectomy up to 24 hours in select cases. Your documentation must prove you acted within appropriate timeframes.

Treatment decisions are scrutinized: Administering tPA or withholding it—either decision will be questioned later. Your note must document why your choice was correct given the clinical picture.

Neurological deficits must be quantified: Vague descriptions like "weak left side" won't cut it. Insurance and quality programs want NIHSS scores or detailed deficit documentation.

Imaging interpretation is critical: You need to document what CT or MRI showed, what you were ruling in or out, and how it influenced your treatment decisions.

Door-to-needle times affect hospital ratings: Get Joint Commission stroke center certification requires documenting specific time stamps throughout the care pathway.

Your CVA note might be reviewed by insurance medical directors, plaintiff attorneys, quality improvement committees, and Joint Commission surveyors—sometimes all for the same case.

Each reviewer is looking for different things, but they're all reading your note.

The Essential Structure of a Defensible CVA Note

Unlike routine outpatient notes, stroke documentation requires specific elements in a specific order to satisfy all the different reviewers.

Here's the framework that protects you:

Last Known Normal Time: Must be documented prominently and clearly. This determines treatment eligibility windows.

Symptom Onset Description: How did symptoms start? Sudden versus gradual onset changes your differential and treatment approach.

Presenting Deficits: Specific neurological findings documented systematically. Not "altered mental status" but "unable to follow commands, dysarthric speech."

NIHSS Score: The standardized stroke severity assessment. Document the total score and key component scores.

Imaging Findings: What the CT/MRI showed, what it ruled out, and any early ischemic changes noted.

Treatment Time Stamps: When symptoms began, when patient arrived, when CT completed, when treatment administered.

Contraindication Review: For tPA cases, document that you reviewed contraindications. For non-tPA cases, document why it wasn't indicated.

Risk-Benefit Discussion: Document conversations with patient/family about treatment options, risks, and their understanding.

Let me show you what this looks like in real clinical scenarios.

Example 1: Acute Ischemic Stroke, tPA Administration

Patient: 68-year-old female
Arrival: 07:45 via EMS
Chief Complaint: Right-sided weakness and speech difficulty
Last Known Normal: 06:30 (witnessed by husband at breakfast)

S – Subjective:

Per EMS report and husband at bedside: Patient was eating breakfast at 06:30 when she suddenly dropped her fork and developed right arm weakness. Unable to speak clearly, words "came out wrong." Husband called 911 immediately. EMS arrival 06:45, hospital arrival 07:45. Last known normal definitively 06:30 (1 hour 15 minutes ago). Patient unable to provide history due to aphasia. No recent trauma, surgery, or bleeding. Husband reports no prior stroke. Patient takes medications for hypertension and diabetes per husband (medication list pending).

O – Objective:

Vital Signs: BP 168/92, HR 88 regular, RR 16, Temp 98.4°F, O2 sat 97% on RA, Glucose 142
Time of initial assessment: 07:50

Neurological Examination (07:55):
Mental Status: Alert but aphasic, unable to follow complex commands, follows simple one-step commands inconsistently
Speech: Expressive aphasia, unable to name objects, significant word-finding difficulty
Cranial Nerves: Right facial droop (lower face), tongue deviates right, visual fields full to confrontation
Motor: Right upper extremity 1/5 (flicker movement only), right lower extremity 2/5 (antigravity movement with drift), left side 5/5 throughout
Sensory: Decreased sensation right hemibody
Reflexes: Hyperreflexia right side, positive Babinski right
Coordination: Unable to assess right side due to weakness
Gait: Not assessed

NIHSS Score (08:00): 16

• LOC: 0
• LOC Questions: 1
• LOC Commands: 1
• Gaze: 0
• Visual: 0
• Facial Palsy: 2
• Motor Arm: 4 (right)
• Motor Leg: 3 (right)
• Ataxia: 0
• Sensory: 1
• Language: 3
• Dysarthria: 1
• Extinction/Inattention: 0

Labs (drawn 07:52): CBC, CMP, PT/INR, aPTT, troponin all within normal limits for tPA administration. INR 1.0, platelets 245K, glucose 142.

CT Head Non-Contrast (completed 08:05): No acute hemorrhage, no mass effect, no midline shift. Hyperdense left MCA sign noted. No definite early ischemic changes. No contraindication to tPA.

CT Angiography Head/Neck (08:10): Left MCA M1 segment occlusion. Vessels otherwise patent.

A – Assessment:

Acute ischemic stroke, left MCA territory, NIHSS 16 (moderate-severe). Last known normal 06:30 (now 1 hour 30 minutes). Patient within treatment window for IV tPA (4.5 hours) and potentially thrombectomy. CT head shows no hemorrhage, hyperdense MCA sign consistent with acute thrombus. CTA confirms left MCA M1 occlusion. No absolute contraindications to thrombolytic therapy identified. BP elevated but below exclusionary threshold (185/110). Labs appropriate for tPA. LKN time reliable per witness. Patient is appropriate candidate for emergent tPA administration followed by consideration for mechanical thrombectomy.

P – Plan:

Acute Stroke Protocol Activated (07:50)

tPA Administration Decision (08:15): Reviewed tPA inclusion and exclusion criteria with stroke team. Patient meets criteria: definite onset time less than 4.5 hours, measurable neurologic deficit (NIHSS 16), CT without hemorrhage, no absolute contraindications. Discussed risks and benefits with husband including bleeding risk (6% symptomatic ICH), potential benefits of early treatment, and alternative of no thrombolytic therapy with higher likelihood of permanent deficits. Husband verbalized understanding and consented to treatment.

tPA Administered:

• Dose calculated: 0.9 mg/kg based on 70 kg = 63 mg total
• Bolus 6.3 mg IV push given at 08:25 (door-to-needle time: 40 minutes)
• Infusion 56.7 mg over 60 minutes started 08:26
• No complications during administration

Blood Pressure Management: Nicardipine drip initiated to maintain BP less than 180/105 during and after tPA per protocol.

Interventional Neurology Consulted: Notified of LVO (large vessel occlusion). Patient being evaluated for mechanical thrombectomy. Transfer to angio suite arranged.

Monitoring: Neuro checks every 15 minutes during tPA infusion and for 2 hours post-infusion. ICU admission arranged. BP monitoring continuous. Second CT head ordered 24 hours post-tPA to assess for hemorrhagic transformation.

Additional Orders: NPO, continuous cardiac monitoring, strict blood pressure parameters, neurosurgery notified and on standby.

Prognosis Discussion: Explained to family that early treatment improves likelihood of recovery but deficits may persist. Will reassess after thrombectomy procedure if performed.

Documentation: All time stamps, NIHSS score, tPA checklist, and consent documented in EMR stroke flowsheet.

---

Example 2: Stroke Mimic, TIA Ruled Out

Patient: 45-year-old male
Arrival: 14:30
Chief Complaint: Left arm numbness and tingling, resolved
Symptom Onset: 13:45, fully resolved by 14:00

S – Subjective:

Patient self-presented to ED reporting sudden onset left arm numbness and tingling that began at 13:45 while sitting at desk at work. Described as "pins and needles" sensation involving entire left arm. Also felt "weird" and dizzy. Symptoms completely resolved by 14:00 (lasted approximately 15 minutes). Denies any residual symptoms currently. No facial droop, speech changes, or leg weakness at any point. No headache, vision changes, or loss of consciousness. Similar episode 6 months ago that also self-resolved, never evaluated. Risk factors: smoker (1 pack daily for 20 years), father had stroke at age 62. No known hypertension or diabetes. Takes no medications.

O – Objective:

Vital Signs: BP 148/88, HR 76 regular, RR 14, Temp 98.6°F, O2 sat 99% on RA, Glucose 98

Neurological Examination (14:35):
Mental Status: Alert, oriented x3, normal speech and comprehension
Cranial Nerves: II-XII intact, no facial asymmetry, tongue midline
Motor: 5/5 strength all extremities, no drift, no ataxia
Sensory: Intact to light touch, pinprick, and proprioception all extremities
Reflexes: 2+ and symmetric throughout, toes downgoing bilaterally
Coordination: Finger-to-nose and heel-to-shin normal
Gait: Normal, steady

NIHSS Score: 0 (no deficits present)

Labs: CBC normal, CMP normal, lipid panel - total cholesterol 245, LDL 162, HDL 38, triglycerides 225

CT Head Non-Contrast (14:45): No acute intracranial abnormality. No hemorrhage, infarction, or mass.

EKG: Normal sinus rhythm, no acute changes, no atrial fibrillation

A – Assessment:

Resolved focal neurological symptoms, etiology unclear. Differential diagnosis includes transient ischemic attack versus migraine aura without headache versus peripheral nerve compression (less likely given symptom description). Patient currently asymptomatic with completely normal neurological examination and NIHSS of 0. CT head negative for acute pathology. However, given sudden onset, complete resolution, vascular risk factors (smoking, family history, dyslipidemia), and prior similar episode, TIA cannot be definitively excluded. ABCD2 score: 4 points (moderate risk). Patient requires further stroke workup as outpatient but not candidate for acute stroke interventions given complete symptom resolution and normal exam.

P – Plan:

Immediate Management: Observed in ED for 4 hours with serial neuro exams - all remained normal. Initiated aspirin 325mg PO x1 dose for antiplatelet effect given possible TIA.

Outpatient Workup Arranged:

• MRI brain with diffusion-weighted imaging scheduled within 48 hours to evaluate for acute infarction (more sensitive than CT)
• Carotid ultrasound doppler scheduled to assess for carotid stenosis
• Echocardiogram with bubble study to evaluate for PFO or other cardiac source of embolism
• 30-day cardiac event monitor to screen for paroxysmal atrial fibrillation

Risk Factor Modification: Started atorvastatin 40mg daily for dyslipidemia. Strongly counseled on smoking cessation - provided resources and offered nicotine replacement. BP borderline elevated, will recheck at neurology follow-up.

Neurology Referral: Urgent outpatient neurology appointment scheduled in 1 week for TIA workup completion and ongoing management.

Patient Education: Explained possibility of TIA and importance of completed workup despite symptom resolution. Reviewed stroke warning signs (F.A.S.T.) and instructed to call 911 immediately if any recurrent symptoms. Emphasized critical importance of completing all scheduled testing.

Disposition: Discharged home with responsible adult. Return precautions given verbally and in writing. Patient verbalized understanding of diagnosis, workup plan, and warning signs.

---

Example 3: Hemorrhagic Stroke, ICU Management

Patient: 72-year-old male
Arrival: 22:15 via EMS
Chief Complaint: Sudden severe headache, vomiting, altered mental status
Symptom Onset: 21:45 per wife (30 minutes prior to arrival)

S – Subjective:

Per EMS and wife: Patient suddenly complained of "worst headache of my life" at 21:45 while watching television. Immediately vomited twice. Wife called 911. During EMS transport, became increasingly lethargic and confused. Patient unable to provide history due to altered mental status. Medical history per wife: hypertension (poorly controlled per wife, "doesn't always take his medicines"), prior MI 5 years ago, takes aspirin and metoprolol but wife unsure of other medications. BP "always runs high" per wife.

O – Objective:

Vital Signs: BP 220/118, HR 92, RR 22, Temp 98.9°F, O2 sat 94% on RA (placed on 2L NC, improved to 98%)
Time of Assessment: 22:20

Neurological Examination:
Mental Status: Lethargic, arouses to painful stimuli, does not follow commands, incomprehensible sounds only
Pupils: 4mm bilaterally, reactive but sluggish
Cranial Nerves: Unable to fully assess due to mental status, gag reflex present
Motor: Moves all extremities to painful stimulus, right side appears weaker (withdraws less briskly)
Reflexes: Brisk throughout, right Babinski present

GCS Score: 9 (E3, V2, M4)

Labs: INR 1.1 (not on anticoagulation), platelets 198K, hemoglobin 14.2, creatinine 1.4

CT Head Non-Contrast (22:25): Large left basal ganglia hemorrhage measuring approximately 4.5 x 3.8 cm with surrounding edema. Mild midline shift (4mm). Intraventricular extension with blood in left lateral ventricle. No hydrocephalus at this time.

CTA Head (22:30): No aneurysm or vascular malformation identified. Hemorrhage appears hypertensive in location and distribution.

A – Assessment:

Acute spontaneous intracerebral hemorrhage (ICH), left basal ganglia, large volume (~35 mL by ABC/2 method). Hypertensive hemorrhage most likely given location (basal ganglia), history of poorly controlled hypertension, and absence of vascular malformation on CTA. GCS 9 with declining mental status. Critically elevated blood pressure (220/118) contributing to ongoing bleeding risk. Intraventricular extension concerning for hydrocephalus development. ICH score: 2 (moderate-severe prognosis). Patient at high risk for herniation given hemorrhage size and edema. Requires emergent blood pressure reduction and intensive monitoring.

P – Plan:

Critical Care Management:

• ICU admission arranged, neurosurgery consulted immediately
• Goal SBP 140-160 per AHA ICH guidelines (patient not on anticoagulation, no contraindication to aggressive BP lowering)
• Nicardipine drip initiated at 22:35, titrating to SBP less than 160
• Head of bed elevated 30 degrees
• Seizure prophylaxis: Levetiracetam 1000mg IV load given

Neurosurgical Evaluation (22:40): Neurosurgeon evaluated patient at bedside. Given hemorrhage location (deep), size, and patient age/comorbidities, surgical evacuation not recommended at this time. Will monitor closely for hydrocephalus development requiring EVD placement.

Monitoring Protocol:

• Neuro checks every 1 hour with GCS scoring
• Continuous BP monitoring with goal SBP 140-160
• Repeat CT head in 6 hours to assess for expansion
• ICP monitoring deferred at this time but low threshold for placement if deterioration

Reversal Agents: Patient on aspirin only - no specific reversal needed. Held all antithrombotic medications.

Prognosis Discussion (23:00): Met with wife and adult children. Explained diagnosis of brain hemorrhage, critical nature of condition, and significant risk of mortality or severe disability. Discussed that next 24-48 hours critical for determining trajectory. Neurosurgery discussed surgical options and reasoning for current conservative approach. Family asking about goals of care - will continue discussion with palliative care consultation if patient's condition deteriorates.

Additional Orders: Prophylaxis for stress ulcer and DVT (SCDs only, no pharmacologic DVT prophylaxis given active ICH). Aspiration precautions, NPO pending swallow evaluation if mental status improves.

---

What Makes CVA Documentation Stand Up to Scrutiny

After reviewing countless stroke notes during quality reviews and legal cases, certain elements consistently separate defensible documentation from problematic notes:

Time Documentation Is Everything

Every stroke note should read like a timeline. Document when symptoms started (last known normal), when patient arrived, when you first assessed them, when imaging completed, when treatments given.

These timestamps prove you acted within appropriate windows and followed stroke protocols.

Neurological Deficits Need Precision

"Weakness" isn't enough. Document which extremities, what strength grade, whether face involved, speech quality, sensory changes, visual fields.

The NIHSS provides this structure—use it. Even if you don't document the full scored NIHSS, your exam should be detailed enough that someone could retrospectively calculate it.

Document Your Thinking Process

When you administer tPA, document why the patient was appropriate: "Met inclusion criteria with symptom onset less than 4.5 hours, measurable deficits, CT without hemorrhage, no absolute contraindications."

When you don't give tPA, document why: "Outside treatment window with LKN greater than 6 hours" or "Symptoms too mild (NIHSS 2) with isolated sensory changes."

Image Interpretation Must Be Clear

Don't just write "CT reviewed." Document what you saw: "CT head shows no acute hemorrhage, no mass effect, no early ischemic changes, no contraindication to thrombolysis."

For hemorrhagic strokes, describe location, approximate size, any midline shift, intraventricular extension.

Risk Discussions Need Documentation

Especially for tPA cases, document that you discussed bleeding risks with the patient or family and that they understood and consented.

For hemorrhagic strokes with poor prognosis, document goals-of-care discussions.

Common CVA Documentation Mistakes That Create Liability

Missing or unclear last known normal time: Without this, you can't prove the patient was within treatment windows. "Sometime this morning" isn't good enough.

Vague neurological deficits: "Left-sided weakness" without specifying upper versus lower extremity, strength grades, or associated findings makes it impossible to assess severity or treatment appropriateness.

No documentation of contraindication review: Even when tPA wasn't given for obvious reasons, document that you considered it and why it wasn't appropriate.

Failure to document NIHSS or equivalent detailed neuro exam: Quality metrics and stroke center certifications require quantified stroke severity.

Missing door-to-needle timestamps for tPA cases: These times determine whether your facility meets quality benchmarks.

Not documenting imaging findings specifically: "CT done" isn't enough. What did it show? What did it rule out?

How SOAP Notes Doctor Handles CVA Documentation

Stroke documentation requires speed and precision simultaneously—documenting at the bedside while racing against time windows.

SOAP Notes Doctor is built to handle this unique challenge:

You can dictate or quickly enter the key clinical details—symptom onset time, NIHSS findings, imaging results, treatment decisions—and the system structures it into a comprehensive note that includes all required elements for stroke center certification, insurance review, and legal protection.

The system prompts for critical time stamps, ensures NIHSS components are documented, includes appropriate clinical decision-making language, and generates notes that meet Joint Commission stroke center requirements.

Visit soapnotes.doctor to see how it can support your stroke documentation workflow.

Final Thoughts

CVA documentation is uniquely challenging because the stakes are so high and the time pressures so intense.

You're making life-or-death decisions in minutes while also needing to create documentation that will be scrutinized for years.

The key is having a systematic approach that captures all essential elements: definitive time stamps, quantified deficits, imaging interpretation, treatment rationale, and risk discussions.

Whether you use SOAP Notes Doctor or document manually, these elements need to be present and clear.

Your documentation should tell the story of your clinical thinking and demonstrate that you provided appropriate, timely stroke care.

When it does that, you're protected—regardless of the outcome.

---

Ready to strengthen your stroke documentation?
Visit soapnotes.doctor and generate comprehensive CVA notes that stand up to any review.