Specialty Exam - Neurology printable pdf download

HIC#

DATE OF SERVICE

SPECIALTY EXAM: NEUROLOGY

System/Body

Elements of Examination

Area

Refer to data section (table below) in order to quantify. After reviewing the medical record documentation, identify

the level of examination. Circle the level of examination with the appropriate grid in Section 5 (Page 3).

Neurological

Evaluation of higher integrative functions including:

Orientation to time, place and person

Recent and remote memory

Attention span and concentration

Performed and Documented

Level of Exam

Language (e.g., naming objects, repeating phrases, spontaneous speech)

One to five bullets

Problem Focused

Fund of knowledge (e.g., awareness of current events, past history, vocabulary)

Six to eleven bullets

Expanded Problem Focused

Test the following cranial nerves:

Twelve or more bullets

Detailed

2nd cranial nerve (e.g., visual acuity, visual fields, fundi)

3rd, 4th, and 6th cranial nerves (e.g., pupils, eye movements)

At least one bullet in the box with the unshaded border

Comprehensive

5th cranial nerve (e.g., facial sensation, corneal reflexes)

AND every bullet in each box with the shaded borders.

7th cranial nerve (e.g., facial symmetry, strength)

(Circle the bullets that are documented.)

8th cranial nerve (

e.g.,

hearing with tuning fork, whispered voice and/or finger rub)

NOTE: For the descriptions of the elements of examination containing the words "and", "and/or", only one (1) of those

9th cranial nerve (e.g., spontaneous or reflex palate movement)

elements must be documented.

11th cranial nerve (e.g., shoulder shrug strength)

System/Body

Elements of Examination

12th cranial nerve (e.g., tongue protrusion)

Area

Examination of sensation (e.g., by touch pin, vibration, proprioception)

Cardiovascular

Examination of carotid arteries (e.g., pulse amplitude, bruits)

Examination of deep tendon reflexes in upper and lower extremities with notation

Auscultation of heart with notation of abnormal sounds and murmurs

of pathological reflexes (e.g., Babinski)

Examination of peripheral vascular system by observation (e.g., swelling,

Test coordination (e.g., finger/nose, heel/knee/shin, rapid alternating movements

varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)

in the upper and lower extremities, evaluation of fine motor coordination in young

children)

Constitutional

Measurement of any three of the following seven vital signs: 1) sitting or

standing blood pressure, 2) supine blood pressure, 3) pulse rate and

regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be

measured and recorded by ancillary staff)

Note:

The Head/Face; Ears, Nose, Mouth and Throat; Neck; Respiratory; Chest (Breasts); GI (Abdomen); GU; Lymphatic; Skin;

General appearance of patient (e.g., development, nutrition, body habitus,

and Psychiatric systems/body areas are not integral parts of this Neurological exam.

deformities, attention to grooming)

(Enter the number of circled bullets in the boxes below. Then circle the appropriate level of care.)

Eyes

Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio,

appearance) and posterior segments (e.g., vessel changes, exudates,

Answer the following two questions. If both

answers are "yes," the appropriate level of

hemorrhages)

exam is comprehensive.

Musculoskeletal

Examination of gait and station

One to Five

Six to Eleven

Twelve or

Was at least one bullet documented in the

(Includes Extremities)

Bullets

more Bullets

unshaded box?

Yes

Assessment of motor function including:

Muscle strength in upper and lower extremities

Was each bullet in each shaded box

documented?

Yes

Muscle tone in upper and lower extremities (e.g., flaccid, cog wheel, spastic)

with notation of any atrophy or abnormal movements (e.g., fasciculation,

Expanded Problem

Problem Focused

Detailed

Comprehensive

tardive dyskinesia)

Focused

10221 11/97

Specialty Exam - Neurology

Related Articles

Related forms

Related Categories