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

Normal Neurological Physical Examination Documentation Template

For routine charting of a normal neurological examination, document the following components systematically, as standardized neurological assessments are essential for accurate communication between healthcare providers and establishing baseline status. 1

Mental Status

• Alert and oriented to person, place, and time 1
• Follows commands appropriately 1
• Normal speech and language without aphasia 1
• Appropriate affect and behavior 2

Cranial Nerves

• CN II-XII: Intact bilaterally 2
  • Pupils equal, round, reactive to light and accommodation (PERRLA)
  • Extraocular movements intact, no nystagmus 1
  • Visual fields full to confrontation 1
  • Facial sensation intact, facial movements symmetric 1
  • Hearing intact bilaterally
  • Palate elevates symmetrically, uvula midline
  • Tongue protrudes midline, no fasciculations
  • Shoulder shrug strong and symmetric

Motor Examination

• Normal muscle bulk and tone in all extremities 2
• Strength 5/5 in all major muscle groups bilaterally:
  • Upper extremities: deltoids, biceps, triceps, wrist extensors/flexors, finger extensors/flexors, intrinsic hand muscles 1
  • Lower extremities: hip flexors/extensors, knee flexors/extensors, ankle dorsiflexors/plantarflexors 1
• No pronator drift with arms extended 1
• No fasciculations or involuntary movements 2

Sensory Examination

• Intact to light touch, pinprick, temperature, vibration, and proprioception in all extremities 1
• No sensory level detected 3
• No extinction to double simultaneous stimulation 1

Coordination and Cerebellar Function

• Finger-to-nose testing: smooth and accurate bilaterally 1
• Heel-to-shin testing: smooth and accurate bilaterally 1
• Rapid alternating movements intact 2
• No dysmetria or ataxia 1

Reflexes

• Deep tendon reflexes 2+ and symmetric bilaterally:
  • Biceps, triceps, brachioradialis 2
  • Patellar, Achilles 3
• Plantar responses: downgoing (flexor) bilaterally 2
• No clonus 2

Gait and Station

• Gait: normal, steady, with normal arm swing 1
• Tandem gait intact 2
• Romberg test: negative (no sway with eyes closed) 2

Additional Components (When Relevant)

• Meningeal signs: absent (no nuchal rigidity, negative Kernig's and Brudzinski's signs) 1
• Perianal sensation: intact (document when assessing for cauda equina syndrome) 3

---

Key Documentation Principles

Always document specific findings rather than simply stating "neurological examination normal," as detailed documentation is required for compliance audits and medicolegal purposes. 4

Use standardized scales when appropriate (such as the NIH Stroke Scale for stroke patients), as these facilitate communication between providers and establish quantifiable baselines. 1, 5

Document any asymmetries or abnormalities with specific details including laterality, severity, and distribution, as precise localization guides diagnostic and therapeutic decisions. 6