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DiraChart Clinical Reference
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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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