A neuro exam is one of the more complex body systems to master when it comes to assessment and documentation. Testing the cranial nerves, for example, takes practice. Omitting a small part of the process can mean missing a potentially serious diagnosis. Given the importance of the neurological exam, today as part of our documentation series, we’re going to look at exactly how to record your exam findings.
What You’re Looking For
The neurological exam consists of a number of components that assess for neurological abnormalities. The level of detail of the neurological exam performed in the clinical setting varies with each patient depending on history and symptoms. Patients presenting with neurological deficits, or symptoms of neurological conditions, for example, may require a complete neurological assessment. Patients presenting for non-neurological complaints may only require a simple assessment of mental status. As a nurse practitioner, it’s your responsibility to determine the appropriate course of action when it comes to assessing your patient.
Overall, a neuro exam may consist of the following:
Sample Basic Normal Exam Documentation:
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. Reflexes are 2+ bilaterally. Cranial nerves are intact. Cerebellar function is intact. Memory is normal and thought process is intact. No gait abnormalities are appreciated.
Sample Detailed Normal Exam Documentation:
If you are documenting a more in-depth neurological exam, your corresponding documentation for a normal exam should look something along the lines of the following:
Mental Status:The patient is alert and oriented to person, place, and time with normal speech. Memory is normal and thought process is intact.
Cranial Nerves: (II, III, IV, VI) Visual acuity 20/20 bilaterally. Visual fields normal in all quadrants. Pupils are round, reactive to light and accommodation. Extraocular movements are intact without ptosis. (V) Facial sensation is intact to bilaterally to dull, sharp, and light touch stimuli. (VII) Facial muscle strength is normal and equal bilaterally. (VIII) Hearing is normal bilaterally. (IX, X) Palate and uvula elevate symmetrically, with intact gag reflex. Voice is normal. (XI) Shoulder shrug strong, and equal bilaterally. (XII) Tongue protrudes midline and moves symmetrically.
Reflexes: Biceps, brachioradialis, triceps, patellar, and Achilles are 2/4 bilaterally. No clonus. Plantar reflex is downward bilaterally.
Sensation: Sensation is intact bilaterally to pain and light touch. Two-point discrimination is intact.
Motor: Good muscle tone. Strength is 5/5 bilaterally at the deltoid, biceps, triceps, quadriceps, and hamstrings.
Cerebellar: Finger-to-nose and heel-to-shin test normal bilaterally. Balances with eyes closed (Romberg). Rapid alternating movements normal. Gait is steady with a normal base. Coordination is intact as measured by heel walk and toe walk.
Sample Abnormal Documentation:
While you won’t use all of these elements in documenting an abnormal neuro exam, here are some examples of neurological abnormalities you may find and record.
Abnormals on a neurological exam may include:
Disoriented to (person, time, place, situation)
Memory impairment noted (acute or chronic)
Decreased muscle strength or tone (flaccid, atrophy)
Hypo or hyperactive reflexes
Cranial nerve deficits
Cerebellar deficits (coordination)
Gait abnormalities (position, speed, balance, heel walking, toe walking)
**Note that this is not a comprehensive guide to neurological assessment or documentation. You are responsible for performing an appropriate physical exam and documentation for your patients.