Neurological Observation Record
Neurological Observation Record
Effective Date: [Original NPP Date]
Revised Date: [Current Date]
Policy:
To ensure the timely and accurate monitoring of residents requiring neurological observations, staff will use the Neurological Observation Record form. This form facilitates the documentation and assessment of critical neurological parameters over specified time intervals.
Residents Name: ____________________________________________________________________ Room #: ___________________
Date |
Time |
BP |
P |
R |
Pupil Response |
Extremity Strength |
Comments: (e.g. changes in emotional state, behavior, speech or consciousness) |
Signature |
||
|
Q 30 min x 4 |
|
|
|
R |
L |
R |
L |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q 1 hour x 4 |
|
|
|
R |
L |
R |
L |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q 8 hours x 48 |
|
|
|
R |
L |
R |
L |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Neuro assessment code: ü - Indicates Normal for Resident * - Indicates Abnormal for Resident – See Nurse’s Notes
References:
-
Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
-
CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]