Can you provide a concise example of a normal neurological examination for charting?

Normal Neurological Examination Documentation

A normal neurological examination for charting should document mental status, cranial nerves, motor function, sensory function, coordination/cerebellar testing, reflexes, and gait as all normal, with specific findings noted for each component. 1

Mental Status

• Alert and oriented to person, place, time, and situation (A&Ox4) 2
• Normal attention and concentration 1
• Appropriate affect and behavior 1

Cranial Nerves

• CN II-XII intact bilaterally 1, 3
• Pupils equal, round, reactive to light and accommodation (PERRLA) 1
• Visual fields full to confrontation bilaterally 4
• Extraocular movements intact, no nystagmus 2
• Facial sensation and strength symmetric 1
• Hearing intact bilaterally 1
• Palate elevates symmetrically, uvula midline 1
• Tongue protrudes midline, no fasciculations 1
• Shoulder shrug symmetric 1

Motor Examination

• Normal muscle bulk and tone in all extremities 1, 3
• Strength 5/5 in all major muscle groups bilaterally (deltoids, biceps, triceps, wrist extensors/flexors, hip flexors, knee extensors/flexors, ankle dorsiflexors/plantarflexors) 1, 3
• No drift with arms extended 5
• No tremor, fasciculations, or abnormal movements 1

Sensory Examination

• Intact to light touch, pinprick, temperature, vibration, and proprioception in all extremities 6, 1
• No sensory level detected 3

Coordination and Cerebellar Function

• Finger-to-nose testing accurate bilaterally 7, 3
• Rapid alternating movements intact 7, 3
• Heel-to-shin testing smooth bilaterally 1, 3

Reflexes

• Deep tendon reflexes 2+ and symmetric bilaterally (biceps, triceps, brachioradialis, patellar, Achilles) 1, 3
• Plantar responses downgoing (negative Babinski) bilaterally 1, 3

Gait and Station

• Gait normal, steady, and coordinated 7, 8
• Tandem gait intact 3
• Romberg test negative 1, 3

Documentation Efficiency Note

The examination components above represent the comprehensive neurological assessment that should be documented when normal. 1, 8 In emergency settings evaluating specific conditions (seizures, stroke, head injury), focused neurological examinations may emphasize particular components relevant to the clinical question while still documenting baseline status of other systems. 2

Common Pitfall

Avoid vague documentation such as "neuro exam normal" or "grossly intact" - specific findings for each component provide medicolegal protection and establish a clear baseline for detecting subsequent changes. 8 This is particularly critical in conditions where neurological deterioration may occur, such as head trauma, stroke, or seizures. 2