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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 a detailed neurological exam?

What is a neurological exam? A neurological exam, also called a neuro exam, is an evaluation of a person's nervous system that can be done in the healthcare provider's office. It may be done with instruments, such as lights and reflex hammers. It usually does not cause any pain to the patient.

What assessments should be performed after a fall?

After the Fall Check the patient's breathing, pulse, and blood pressure. ... Check for injury, such as cuts, scrapes, bruises, and broken bones. If you were not there when the patient fell, ask the patient or someone who saw the fall what happened.

What would you include when completing the neurological assessment?

A complete neurologic examination should contain an assessment of sensorium, cognition, cranial nerves, motor, sensory, cerebellar, gait, reflexes, meningeal irritation, and long tract signs.

What are the 5 steps in the neurological assessment?

It should be assessed first in all patients. Mental status testing can be divided into five parts: level of alertness; focal cortical functioning; cognition; mood and affect; and thought content.

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What does a neurological exam consist of?

The neurologic examination is typically divided into eight components: mental status; skull, spine and meninges; cranial nerves; motor examination; sensory examination; coordination; reflexes; and gait and station. The mental status is an extremely important part of the neurologic examination that is often overlooked.

What are the 7 areas of documentation of the neurological exam?

The neurological exam can be organized into 7 categories: (1) mental status, (2) cranial nerves, (3) motor system, (4) reflexes, (5) sensory system, (6) coordination, and (7) station and gait.

What are the 4 components of a neurological check?

Components of a Neurological Examination Mental Status. This is usually assessed through observation and interaction during routine health questions that are asked. ... Motor Function. The physician may evaluate muscle tone and strength. ... Balance. ... Coordination. ... Sensation. ... Reflexes. ... Results.

What does a neurological assessment show?

A neurological examination assesses motor and sensory skills, hearing and speech, vision, coordination, and balance. It may also test mental status, mood, and behavior. The examination uses tools such as a tuning fork, flashlight, reflex hammer, and a tool for examining the eye.

What are the 5 components of a neurological examination?