How do you document neurological exams?

Documentation of a basic, normal neuro exam should look something along the lines of the following: The patient is alert and oriented to person, place, and time with normal speech. No motor deficits are noted, with muscle strength 5/5 bilaterally. Sensation is intact bilaterally.

What is included in a neurological examination?

The types of tests will depend on your symptoms, but most neurological exams include tests of some or all of the following:

  • Mental status.
  • Coordination and balance.
  • Reflexes.
  • Sensation.
  • Cranial nerves.
  • Autonomic nervous system.

How do you write a good history of present illness?

It should include some or all of the following elements:

  1. Location: What is the location of the pain?
  2. Quality: Include a description of the quality of the symptom (i.e. sharp pain)
  3. Severity: Degree of pain for example can be described on a scale of 1 – 10.
  4. Duration: How long have you had the pain.

What are the 6 general components of the neurological exam?

What is done during a neurological exam?

  • Mental status.
  • Motor function and balance.
  • Sensory exam.
  • Newborn and infant reflexes.
  • Reflexes in the older child and adult.
  • Evaluation of the nerves of the brain.
  • Coordination exam:

What are the four components of a rapid neurological assessment?

Rapid Neurological Exam Checklist

  • Eyes – Can patient see, is vision normal, is eye movement normal.
  • Hearing – Can patient hear equally in both ears, is hearing normal.
  • Smell – Can patient smell (coffee, peppermint, etc.)
  • Facial Muscles – Is the face equal in muscle tone and control, have patient smile.

How do you write a brief history of a patient?

Procedure Steps

  1. Introduce yourself, identify your patient and gain consent to speak with them.
  2. Step 02 – Presenting Complaint (PC)
  3. Step 03 – History of Presenting Complaint (HPC)
  4. Step 04 – Past Medical History (PMH)
  5. Step 05 – Drug History (DH)
  6. Step 06 – Family History (FH)
  7. Step 07 – Social History (SH)

How often should neuro checks be done?

Historically, early recommendations included indefinite GCS observation every 10-15 minutes1; neuro checks every 15 minutes for the first hour, every 30 minutes for an hour, and then every hour2; and a maximum of one hour between neuro checks.