What is an example of a normal neurological physical examination for charting?

Normal Neurological Physical Examination for Charting

A normal neurological examination for documentation should include mental status, cranial nerves, motor function, sensory function, reflexes, coordination, and gait, with each component explicitly documented as normal or intact.

Mental Status

• Alert and oriented to person, place, time, and situation 1
• Normal attention and concentration 1
• Follows commands appropriately 1
• Speech fluent without aphasia 1, 2

Cranial Nerves

• CN II-XII intact, including:
  • Visual fields full to confrontation bilaterally (no hemianopia) 1, 2
  • Extraocular movements intact, no nystagmus 1
  • Facial sensation and strength symmetric 1
  • Hearing intact bilaterally 1
  • Palate elevates symmetrically 1
  • Tongue midline without deviation 1

Motor Examination

• Normal muscle tone throughout 1
• 5/5 strength in all major muscle groups bilaterally (deltoids, biceps, triceps, wrist extensors/flexors, hip flexors, quadriceps, hamstrings, ankle dorsiflexion/plantarflexion) 1
• No pronator drift 1
• No atrophy or fasciculations 3

Sensory Examination

• Intact to light touch, pinprick, temperature, vibration, and proprioception in all extremities 4
• No sensory level or dermatomal deficits 4

Reflexes

• Deep tendon reflexes 2+ and symmetric (biceps, triceps, brachioradialis, patellar, Achilles) 3
• Plantar responses downgoing bilaterally (negative Babinski) 3

Coordination

• Finger-to-nose and heel-to-shin testing normal bilaterally 3
• Rapid alternating movements intact 3
• No dysmetria or intention tremor 3

Gait and Station

• Gait normal and steady 3
• Tandem gait intact 3
• Romberg test negative 3

Key Documentation Principles

The American Heart Association emphasizes that standardized neurological assessments improve communication between healthcare providers and ensure comprehensive evaluation 1. Using structured formats like the NIH Stroke Scale components (even for non-stroke patients) ensures all critical elements are assessed 1, 3.

Common pitfall: Avoid vague documentation such as "neuro exam normal" or "grossly intact" without specifying which components were actually tested 3, 5. Each element should be explicitly documented to demonstrate a thorough examination was performed and to establish a baseline for future comparison 3, 6.

For efficiency in routine cases, you may document: "Alert and oriented x4. CNs II-XII intact. Motor 5/5 throughout, no drift. Sensation intact to all modalities. DTRs 2+ symmetric, plantars downgoing. Coordination and gait normal." 3, 5