NEUROLOGICAL ASSESSMENT FLOW SHEET

INSTRUCTIONS: Document the date and time of each assessment, then proceed as follows:
LEVEL OF CONSCIOUSNESS - Check () the appropriate response*.
PUPIL RESPONSE - Check () PERL* if applicable or enter the appropriate code* for each eye.
MOTOR FUNCTIONSHAND GRASPS - Enter the appropriate code*.
EXTREMITIES - Check () the appropriate column(s)*.
PAIN RESPONSE - Check () the appropriate column*.
VITALS - Record blood pressure, temperature, pulse and respiration in the appropriate columns.
Use the OBSERVATION column to note the presence or absence of specific resident conditions and place signature in the appro-
priate column to verify documentation. * In all instances, refer to the legends provided at the bottom of the form.
*LEVEL OF * PUPIL MOTOR FUNCTIONS *PAIN
DATE TIME CONSCIOUSNESS VITALS OBSERVATIONS SIGNATURE
RESPONSE * EXTREMITIES RESPONSE (i.e. seizures, headaches,
*HAND
vomiting, paralysis)
A D S C PERL RIGHT LEFT GRASPS MA RU LU RL LL U AB A I AB BP TEMP P R

o m

E
r p .c
o

ww
. B r i gg s C

P L
A
w
M 4 7 - 2 3 4 3

S
) 2
0 0
(8

CONSCIOUSNESS PUPIL RESPONSE HAND GRASPS EXTREMITIES PAIN RESPONSE

A - Alert PERL- Pupils equal and = - Hand grasps equal MA - Moves all extremities A - Appropriate pain
D - Drowsy reactive to light R>L - Right grasp greater RU - Moves right arm response
B - Brisk
S - Stuporous than left LU - Moves left arm I - Inappropriate pain
S - Sluggish
C - Comatose NR - Nonreactive L>R - Left grasp greater than right RL - Moves right leg response
PP - Pinpoint LL - Moves left leg
DIL - Dilated
U - Unable to follow commands AB - No response to pain
U - Unable to follow commands
FX - Fixed AB - Absent AB - Absent

NAMELast First Middle Attending Physician Record No. Room/Bed

CFS 6-19HF Rev. 12/03 1992 BRIGGS, Des Moines, IA (800) 247-2343 NEUROLOGICAL ASSESSMENT FLOW SHEET
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