In many regions  in Quebec, early-intern units and communauty rehabilitation services are provided to stroke patients, by different teams in different settings (hospitals, hospital’s external facilities, external clinics) who have their own admission process. This situation can lead to some additionnal delay or breakdown in services during the transition phases. Because the registry information systems for patients used in hospitals and rehabilitation settings are different, no one is aware of what might go wrong in transition. 
In the Laurentian region, heads of many rehabilitation programs have set up a simple tool (Excel program) enabling us to track and report patients, who had suffered a stoke, from their hospitalisation to their release to external rehabilitation care. The rehabilitation tracking/reporting grid  (Rehab TRG) is designed to be easely filled with information regarding patient’s course of care and helping caregivers to identify and keep track of patients. The informations compiled in the grid are also easy to access in day to day care organisation and allows easy calculation of different deadlines to meet. An annual report  made from the collected informations allows readjustments of clinical rehabilitation path. 
The Rehab TRG keeps institutions related to each other by improving access and continuity care for patients who are recovering from a stroke. Great benefits have been gained with the use of what became a precious information system permitting us to be connected in a climate of transparency.

THE REHABILITATION TRACKING/REPORTING GRID: A TOOL WHO CONNECTS EARLY-INTERN UNIT AND COMMUNAUTY REHABILITATION FOR CONTINUUS CARE OF STOKE PATIENTS