neurologic documentation PA module 7

Student Name: ______________________________________

Date: _________________

Points Possible

Points Earned

Comments

Pre-Procedure Steps

Knocks

1

Washes hands

1

Identifies the client with 2 identifiers

1

Provides privacy

1

Explains procedure

1

Identifies any issues that may impact client safety or personal safety

1

Mental Status

Assess level of consciousness and orientation to person, place, and time

1

Assess quality and appropriateness of speech

1

Cranial Nerves

Cranial Nerve I (Olfactory) – tests for smell

5

Cranial Nerve II (Visual) – tests for visual acuity OR peripheral vision

5

Cranial Nerves III, IV, and VI (Oculomotor, Trochlear, Abducens) – tests for 6 cardinal directions of gaze

5

Cranial Nerve V (Trigeminal) – tests for facial sensation and jaw strength

5

Cranial Nerve VII (Facial) – tests for facial movement

5

Cranial Nerve VIII ( Acoustic) – tests for hearing acuity

5

Cranial Nerve IX (Glossopharyngeal) – tests for swallow

5

Cranial Nerve X (Vagus) – tests for uvula rising with phonation

5

Cranial Nerve XI (Spinal Accessory) – tests shoulder shrug and head turn against resistance

5

Cranial Nerve XII (Hypoglossal) – tests for midline tongue protrusion

5

Reflexes

Triceps reflex

5

Biceps reflex

5

Brachioradialis reflex

5

Patellar reflex

5

Achilles’ tendon reflex

5

Plantar reflex

5

Coordination

Finger to Nose test

1

Heel to shin test

1

Romberg test

1

Motor Testing

Tests grip strength

1

Tests dorsiflexion and plantar flexion strength

1

Sensory Testing

Tests sharp and dull sensation minimum of 2 areas of arms and legs bilaterally

1

Tests position sense of 1 finger on each hand and 1 toe on each foot

1

Student Name: ______________________________________

Date: _________________

Points Possible

Points Earned

Comments

Post-Procedure Steps

Inquires if the client is comfortable

1

Student is professional and courteous with their communication

1

Ensures the client has their call light

1

Ensures client’s personal items are within reach (glasses, phone, etc.)

1

Washes hands

1

Total Points Earned

of 100 possible

The above named student has:

Passed this skill evaluation

Failed this skill evaluation and must remediate. Plan for remediation:

Student signature and date indicating agreement with remediation plan: _____________________________________

Instructor signature and date indicating agreement with remediation plan: ___________________________________