Neurological

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Trace DC20-3

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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2. What the clinician must assess

A complete assessment addresses each of the following each visit, scaled to the patient's diagnosis and stability:

  • Level of consciousness and mental status — alertness and orientation (detailed cognition in Cognitive / Mental Status).
  • Cranial-nerve screen — facial symmetry, speech, swallowing, pupils (equality and reactivity), and extraocular movements and visual fields.
  • Motor function — strength by major muscle group with side-to-side symmetry, pronator drift, and tone.
  • Sensory screen — light touch and gross sensation (detailed sensory mapping in Touch / Sensation).
  • Coordination — finger-to-nose and rapid alternating movements.
  • Gait and balance (assessed with Function and Safety).
  • Speech — dysarthria or aphasia (with Communication), and any headache, dizziness, or seizure activity.
  • Signs of an acute stroke (a F.A.S.T. / BE-FAST screen) and any focal deficit or change from the patient's neurologic baseline.
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