[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-166317-en":3,"doc-seo-166317-105":29,"detail-sidebar-cat-1-en-105":89},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":11,"category_id":12,"category_name":13,"doc_title":14,"doc_description":15,"doc_content":16,"file_id":17,"file_url":18,"file_type":19,"file_size":20,"view_count":4,"is_deleted":4,"is_public":11,"is_downloadable":11,"audit_status":11,"page_count":21,"language":22,"language_code":23,"site_id":24,"html_lang":23,"table_of_contents":25,"faqs":26,"seo_title":27,"seo_description":15,"update_tm":28,"read_time":11},166317,1099523885336,"Taylor Morgan","https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c",1,17,"Forms","Neuro SOAP note template","Neuro SOAP note template for documenting a neurological patient encounter in a structured way. It covers subjective history, objective vitals and intake/output, and a full systems examination including general appearance, cardiovascular, respiratory, abdominal, mental status, cranial nerves with suggested tests, motor tone and strength, coordination, sensory testing, gait, reflexes, and relevant dermatomal mapping. It also includes labs and imaging placeholders, an assessment/plan one-liner and problem list options, plus supporting clinical reference tools such as imaging sequence basics and Glasgow Coma Scale scoring.","Neuro SOAP note template\nDate, time\nMS3PN\nS: any complaints the pt has, how they are doing, what happened yesterday\nO: Vitals (Tmax, Pulse (min-max), Respiration (min-max), BP (min-max), SaO2)\nIns and Outs (over 24h). *note last BM when going to Dodd\nExam:\nGeneral: how does patient appear?\nCV: RRR (regular rate and rhythm)?, normal S1 and S2?, no m/r/g (murmurs/rubs/gallops)?, peripheral pulses 2+ bilaterally?, peripheral edema?\nLungs: CTAB (clear to auscultation bilaterally)?, no wheezes/rales/rhonchi?, no accessory muscle use?\nAbd: soft?, NT/ND (nontender/nondistended)?, bowel sounds normal?, no palpable masses or organomegaly?\nMental Status: awake/somnolent/drowsy/arousable (to pain/name, etc?)/ comatose\nCN : EOMI (extraoccular mvts intact), PERRLA (pupils equally round and reactive to light and accommodation), face symmetric/droop, palate elevation symmetric/asymmetric, facial sensation intact ?/ tongue midline?\n* what to test with CN’s\nII: visual acuity, fields, pupils\nIII, IV, VII: extraoccular movements, corneal reflex (if you are mean)\nV, VI: facial sensation, movement\nIX, X, XII: palate tongue, gag reflex, shoulder shrug/SCM\nMotor: tone (nl/spastic/flaccid)\nBulk: atrophy?\nStrength:\nSA/EF/EE/WE/WF/DI/HF/KE/DF/PF\nR ____________________________________\nL\n*(shoulder abd, elbow flex, elbow ext, wrist flex, wrist ext, dorsal interossi, hip flex, knee flex, dorsiflexion, plantarflextion) scale of 1-5 (5 = normal)\nCoordination: finger to nose, heel to shin, rapid alternating movements\nSensory: safety pin prick/vibration/proprioception/temperature\nGait: stance/stride/ arm swing/tandem walk/steadiness with feet together & eyes  closed\nDTR (deep tendon reflexes)\nO\n\\   |   /     *note biceps, triceps, brachioradialis, patellar, Achilles reflexes\n|  .          scale of 1 -4 (2 = normal)\n/        \\ .\n*annotate with arrows if toes are upgoing or downgoing.\nLabs: Na |Cl   |BUN /glucose             \\ Hgb /\nK  |CO2|Cr     \\                WBC / Hct \\ plt\nMRI, CT studies, consults, etc.\nA/P: “one liner” about pt “Mr Murphy is a 45 y/o right handed WM with a history of ___ who presented with _____. Sometimes, make a comment about their condition if it has changed since admit “s/p (status post) TPA with improvement in left leg weakness”\nProblem list (can be done by problems or by systems)\nNeuro  ( a. problem or ddx/ b. diagnostic studies/ c. treatment plan )\nEndo\nCardio\nEtc…..\nJoe Smith, MS3\n346-xxxx (pager #)\nDTRs:\t\t\t\t\t\tDermatomes:\nBiceps = C5, C6\t\t\t\t\tT4 = nipple line\nBrachioradialis = C5, C6\t\t\t\tT10 = umbilicus\nTriceps = C6, C7\t\t\t\tL1 = inguinal ligament\nPatellar = L4\nNO L5 reflex\t\t\t\t\tCaloric eye testing – normal eye movements\nAchilles = S1\t\t\t\t\tCOWS\nCold - Opposite\nWarm - Same\nMRI\nT1 – image looks like brain – ie white matter is white, gray matter darker, CSF black, best for anatomy of brain\nT2 – inverse of T1 – white matter is dark, gray matter lighter, CSF white, pathology stand out better (edema has a large water component)\nDWI – diffusion weighted images – type of T2 sequence that can identify ischemic areas within minutes of onset\nGlasgow Coma Score – out of 15\nVerbal \t\t\t\tEye opening\t\t\tMotor\n6 – follows commands\n5 – oriented\t\t\t\t\t\t\t5 – localizes pain\n4 – confused\t\t\t4 – spontaneous\t\t\t4 – withdraws from pain\n3 – inappropriate words\t\t3 – to voice\t\t\t3 – flexion/decorticate posturing\n2 – incomprehensible\t\t2 – to painful stim\t\t2 – extension/decerebrate\n1 – no response\t\t\t1 – no eye opening\t\t1 – no response\nCauses of delirium – MOVE, STUPID\nMetabolic\nOxygen\nVascular\nEndocrine/Electrolyte\nSeizures\nTumor/Trauma/Temperature\nUremia\nPsychogenic\nInfection/Intoxication\nDrugs/Degenerative disease","cbCairF5jxdX2RyY","https://ap.wps.com/l/cbCairF5jxdX2RyY","doc",35840,2,"English","en",105,"# Neuro SOAP note template\n## S: Subjective\n## O: Objective\n## Exam\n## Labs and imaging\n## A/P: Assessment and Plan\n## Reference sections","[{\"question\":\"What should be included in the SOAP note’s S (Subjective) section?\",\"answer\":\"Record the patient’s complaints, how they are doing, and key events since the previous day or since admission, including relevant status changes.\"},{\"question\":\"What objective data does the O (Objective) section require?\",\"answer\":\"Document vitals (including Tmax, pulse, respiration, BP, SaO2), track intake and output over 24 hours, and record key exam elements and last bowel movement timing when applicable.\"},{\"question\":\"How is the A/P portion of the note structured?\",\"answer\":\"Write a concise one-liner summarizing the patient’s key history and presentation, then list problems either by specific problems or by organ systems, including diagnostic studies and treatment plan per problem.\"}]","Neuro SOAP note template | 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should be included in the SOAP note’s S (Subjective) section?","Question",{"text":73,"@type":74},"Record the patient’s complaints, how they are doing, and key events since the previous day or since admission, including relevant status changes.","Answer",{"name":76,"@type":71,"acceptedAnswer":77},"What objective data does the O (Objective) section require?",{"text":78,"@type":74},"Document vitals (including Tmax, pulse, respiration, BP, SaO2), track intake and output over 24 hours, and record key exam elements and last bowel movement timing when applicable.",{"name":80,"@type":71,"acceptedAnswer":81},"How is the A/P portion of the note structured?",{"text":82,"@type":74},"Write a concise one-liner summarizing the patient’s key history and presentation, then list problems either by specific problems or by organ systems, including diagnostic studies and treatment plan per 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