Neuro SOAP Note

Question 1

S:

Answer 1

slide

Question 2

O:

Answer 2

Vitals: T: BP: P: R:

General: 
Eyes:
Ears:
Sinus:
Lungs:
Heart:
OMM:
Neuro:

Question 3

How do you document neuro?

Answer 3

Roman numerals
Sensation intact to light tough and pinprick.
Strength 5/5 in upper and lower extremities
Reflex: 2+ bilaterally
Negative Romber and Pronator drift.
Gait (Heel to toe, etc.) intact

Question 4

Assessment and Plan guidelines

Answer 4

Plan needs to be aligned with the assessment. 1A and 1P