Stroke Follow-Up After Hospital Discharge

The discharge summary is the most important paper you own

Leaving hospital after a stroke, families are handed a stack of papers. The one that matters most is the discharge summary. It says what kind of stroke it was, which part of the brain was involved, what treatment was given, which medicines to continue, and when to come back. Every doctor and therapist you see afterwards will ask for it.

Read it before you leave the ward, while staff are still there to answer questions. If the follow-up date isn't written, ask. If a medicine was stopped or changed, ask why. If there are instructions about blood pressure targets, sugar control or swallowing ("soft diet only", "thickened fluids"), make sure you understand them. Photograph every page and keep the originals in one folder.

The first week at home

Expect it to be harder than the hospital made it look. On the ward, beds were the right height, nurses turned the person, and help came when the bell rang. At home, the bed is low and against the wrong wall, the bathroom is down a corridor, and the family is learning everything at once.

Some things to settle in the first few days. Where will the person sleep, and can they get out on their stronger side? How will they get to the toilet at night, and is a commode safer for now? Who gives the medicines, at what times? Is someone checking blood pressure and, for diabetics, sugar, as advised? Is the person drinking enough water, especially if swallowing is slow? Our guide to everyday care for a stroke patient at home goes through the daily routine, and positioning in bed covers how to protect the weak side.

If caring round the clock isn't possible for the family, short-term nursing help can bridge the first weeks. See stroke patient nursing care at home.

Follow-up appointments with the neurologist

Most hospitals schedule a first review within a few weeks of discharge, though the timing varies. This visit is mainly about preventing another stroke: checking blood pressure control, reviewing blood thinners or cholesterol medicines, looking at test results, and asking about new symptoms.

Go prepared. Bring the discharge summary and all medicine strips, not just a list. Bring a written log of blood pressure readings (and sugar readings if relevant), taken at roughly the same times each day. Write your questions down beforehand, because they disappear the moment you sit in the consulting room. Useful ones: Is it safe to increase activity? Are there limits on lifting or bending? When should the next scan or test be done? Is this tiredness or dizziness expected?

Tell the doctor about anything new since discharge: falls, confusion, coughing while eating, low mood, pain in the shoulder, or swelling in a leg.

Medicines: sticking with them

We don't advise on medicines; that is the treating doctor's job. But we see one problem often enough to mention it. Families stop or skip a medicine because the person "seems fine now", or because a neighbour said it was too strong, or because a strip ran out over a long weekend. Blood pressure medicines, blood thinners and cholesterol medicines after a stroke are there to reduce the risk of another one. Changing them without the doctor's advice is risky.

Practical help: a weekly pill organiser with morning, afternoon and night slots; an alarm on the phone; one family member responsible for refills. If the person has trouble swallowing tablets, ask the doctor or pharmacist whether alternatives exist, rather than crushing them on your own, since some tablets shouldn't be crushed.

Starting physiotherapy: home or clinic

Physiotherapy should ideally continue without a long gap after discharge. The early months are when the brain is most responsive to practice, and they're also when complications like stiff joints and shoulder pain set in if the person stays in bed. Read our stroke recovery timeline for why that window matters.

For most people just home from hospital, physiotherapy after a brain stroke starts at home, because getting into a car is hard and tiring. The first visit includes a full rehabilitation assessment and a written plan, and part of each session goes into training the family in transfers and safe walking. Once travelling is comfortable, sessions can move to the clinic in Indirapuram, where equipment like the harness system is available. We share progress notes so the neurologist knows how things are going.

The 6 month stroke review

Many stroke services recommend a broader review around six months after the stroke, and again at a year. If your doctor doesn't bring it up, it is reasonable to ask for one. It is a chance to step back from week-to-week progress and look at the whole picture.

• How independent the person is in daily tasks compared with discharge.
• Whether muscle stiffness (spasticity) is getting in the way and needs medical review.
• Falls in the last few months, and why they happened.
• Mood, sleep and fatigue. Depression after a stroke is common and treatable.
• Memory, attention and communication.
• How well blood pressure, sugar and cholesterol are controlled.
• Questions about work, driving, travel and returning to normal life.

Progress in the second six months is often slower, but it doesn't stop. Our page on recovery after six months or a year explains what can still change and how.

The papers to keep in one folder

A single folder, kept in a known place and taken to every appointment, saves a great deal of trouble. Keep the discharge summary and all scan reports, the current prescription with any changes written on it, recent blood test reports, the BP and sugar log, physiotherapy progress notes, and a one-page note of emergency contacts and the person's medical conditions. If the person is ever admitted again, especially to a different hospital, this folder lets the new team understand the history quickly. For the long view beyond the first months, see our guide to long-term care after a stroke.

Frequently asked questions