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: ___________________________________

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Subjective

(4 Pts)

Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.

Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.

Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.

Points: 1

Points: 2

Points: 3

Points:4

Objective

(4 Pts)

Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”.

Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings.

Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information

Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information

Points: 1

Points: 2

Points: 3

Points: 4

Actual or Potential Risk Factors

(2 pts)

Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion.

Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them.

Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Points: 0.5

Points: 1

Points: 1.5

Points: 2