Neurological

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Trace DC20-6

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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4. Normal findings

The reference range below is the yardstick for “normal/at-baseline.” Normal findings are documented in Mode A with the skilled rationale that follows in Section 6 — never as “WNL” alone.

  • Alert with mental status at baseline.
  • Cranial nerves grossly intact — symmetric face, clear speech, intact swallow, pupils equal and reactive, and full extraocular movements and visual fields.
  • Motor strength 5/5 and symmetric with no pronator drift and normal tone.
  • Sensation grossly intact.
  • Coordination intact.
  • Gait steady (with the usual device).
  • No focal deficits and a negative stroke screen — at the neurologic baseline.
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