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Neurology: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

What is a neurology SOAP note?

A neurology SOAP note is a structured clinical documentation format for neurological encounters that includes Subjective symptoms, Objective exam findings (cranial nerves, motor, sensory, reflexes, coordination, gait), Assessment with diagnosis and localization, and a detailed treatment Plan. Neurology notes require precise documentation of complex neurological examinations, including standardized grading scales for strength, reflexes, and cognitive function.

Neurology SOAP notes require precise documentation of complex neurological examinations, detailed assessment of nervous system function, and careful tracking of neurological conditions over time. This comprehensive guide provides detailed instructions for documenting neurological encounters, from routine follow-ups to acute stroke evaluations, helping you create thorough and clinically accurate notes.

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Subjective Section (S)

The Subjective section captures the patient's neurological symptoms and history. Neurology patients often present with complex symptom combinations requiring detailed characterization.

Subjective Section (S) Components

  1. Chief Complaint:

    • The primary neurological symptom or concern
    • Use the patient's own words when possible
    • Example: "I've been having severe headaches with flashing lights for the past month"

  2. History of Present Illness:

    • Detailed chronology of the neurological symptoms
    • Onset (sudden vs gradual, exact time if acute)
    • Duration, frequency, and progression
    • Character and quality of symptoms
    • Aggravating and relieving factors
    • Associated symptoms
    • Impact on function and activities
    • Previous similar episodes
    • Example: "Patient reports sudden onset of right-sided weakness that began at 8:30 AM today while eating breakfast. Weakness progressed over 5 minutes to involve the right arm and leg. Also noted slurred speech and right facial droop. Symptoms persist without improvement. No prior similar episodes."

  3. Neurological Review of Systems:

    • Headaches (frequency, character, associated symptoms)
    • Weakness or paralysis (location, onset, progression)
    • Numbness or tingling (distribution, pattern)
    • Vision changes (double vision, visual loss, visual disturbances)
    • Speech or language difficulties
    • Swallowing problems
    • Dizziness or vertigo
    • Seizures or spells (description, frequency)
    • Memory or cognitive changes
    • Coordination or balance problems
    • Tremor or involuntary movements
    • Falls

  4. Past Neurological History:

    • Previous neurological diagnoses
    • Prior strokes, TIAs, or seizures
    • Head trauma or concussions
    • Neurosurgical procedures
    • Neurological hospitalizations
    • Imaging studies (MRI, CT) and results

  5. Medications:

    • All current medications with doses
    • Neurological medications (anticonvulsants, dopaminergics, migraine prophylaxis)
    • Medication adherence and tolerability
    • Recent medication changes
    • Antithrombotic medications (aspirin, anticoagulants)

  6. Risk Factors:

    • Vascular: hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation
    • Family history: stroke, aneurysms, seizures, neurodegenerative diseases
    • Lifestyle: alcohol use, drug use, sleep patterns, stress

  7. Functional Status:

    • Baseline functional abilities before current symptoms
    • Impact of neurological condition on ADLs
    • Mobility status and assistive devices used
    • Driving status
    • Employment or disability status

Example Subjective Section for Neurology

Subjective (S)
 
 
Chief Complaint: 'I'm having trouble with my balance and I keep falling'
 
History of Present Illness:
67-year-old right-handed woman with history of hypertension and type 2 diabetes presents with progressive balance difficulty and falls over the past 6 months. Patient reports feeling unsteady when walking, particularly in the dark or on uneven surfaces. Has had 4 falls in the past 2 months, most recently yesterday when turning around in the bathroom. No loss of consciousness with falls. Also notes numbness in both feet up to the ankles, described as 'like walking on cotton.' Denies weakness, but reports legs feel 'heavy' when climbing stairs.
 
Associated symptoms include occasional sharp, shooting pains in both legs, worse at night. No bowel or bladder incontinence. No tremor, rigidity, or slowness of movement noted.
 
Review of Systems:
- Constitutional: Denies fever, weight loss
- Neurological: Positive for numbness, balance problems, falls as above. Denies headache, dizziness, weakness, visual changes, speech difficulty, cognitive changes, seizures
- Cardiovascular: Denies chest pain, palpitations, orthostatic symptoms
 
Past Neurological History:
No prior strokes, seizures, or neurological diagnoses. Denied history of head trauma. Denied prior neurological imaging.
 
Medications:
- Lisinopril 20 mg daily for hypertension
- Metformin 1000 mg twice daily for diabetes
- Atorvastatin 40 mg nightly
- Aspirin 81 mg daily
 
Risk Factors:
- Type 2 diabetes for 12 years, HbA1c last month 8.2%
- Hypertension for 15 years
- No tobacco use
- Occasional alcohol (1-2 drinks per week)
 
Functional Status:
Previously independent with all ADLs. Now requires son's assistance with shopping due to fear of falling. Uses a cane for outdoor ambulation. Stopped driving last month due to safety concerns. Lives alone in single-story home.
 

Objective Section (O)

The Objective section documents the complete neurological examination with specific, measurable findings. Precise documentation of laterality and anatomical localization is critical.

Objective Section (O) Components

  1. Vital Signs:

    • Blood pressure (both arms if indicated)
    • Heart rate and rhythm
    • Temperature
    • Respiratory rate
    • Oxygen saturation
    • Weight (for medication dosing)

  2. General Appearance:

    • Level of alertness and cooperation
    • Apparent distress
    • Posture and positioning
    • Hygiene and self-care

  3. Mental Status Examination:

    • Level of consciousness: Alert, lethargic, obtunded, stuporous, comatose (Glasgow Coma Scale if altered)
    • Orientation: Person, place, time, situation
    • Attention: Serial 7s, months backward, digit span
    • Memory: Immediate (repeat 3 words), short-term (recall at 5 minutes), long-term (personal history, current events)
    • Language: Fluency, comprehension, repetition, naming
    • Visuospatial: Clock drawing, copying figures
    • Executive function: Similarities, judgment, insight
    • Formal cognitive testing: MoCA, MMSE scores if performed

  4. Cranial Nerves (I-XII):

    • CN I (Olfactory): Smell testing if indicated
    • CN II (Optic): Visual acuity, visual fields by confrontation, fundoscopy (discs, hemorrhages)
    • CN III, IV, VI (Oculomotor, Trochlear, Abducens): Pupils (size, symmetry, reactivity), extraocular movements, nystagmus, ptosis
    • CN V (Trigeminal): Facial sensation (V1, V2, V3 divisions), corneal reflex, muscles of mastication
    • CN VII (Facial): Facial strength and symmetry (forehead, eye closure, smile), taste if indicated
    • CN VIII (Vestibulocochlear): Hearing, Rinne and Weber tests if indicated
    • CN IX, X (Glossopharyngeal, Vagus): Palate elevation, gag reflex, voice quality
    • CN XI (Accessory): Shoulder shrug (trapezius), head turn (sternocleidomastoid)
    • CN XII (Hypoglossal): Tongue protrusion, strength, fasciculations

  5. Motor Examination:

    • Bulk: Normal, atrophy (specify location), hypertrophy
    • Tone: Normal, increased (spasticity, rigidity), decreased (flaccidity)
    • Strength: Graded 0-5/5 for each muscle group bilaterally
      • 0/5: No contraction
      • 1/5: Flicker of contraction
      • 2/5: Movement with gravity eliminated
      • 3/5: Movement against gravity
      • 4/5: Movement against some resistance (can specify 4-/5 or 4+/5)
      • 5/5: Normal strength
    • Document specific muscle groups: deltoids, biceps, triceps, wrist extensors/flexors, finger flexors/extensors/abductors, iliopsoas, quadriceps, hamstrings, dorsiflexors, plantarflexors
    • Drift: Pronator drift testing (arms extended, eyes closed)
    • Fasciculations: Present or absent, location if present

  6. Sensory Examination:

    • Light touch: By dermatomes or anatomical regions
    • Pinprick: Sharp/dull discrimination
    • Vibration: 128 Hz tuning fork at bony prominences (great toes, ankles, knees, fingers)
    • Proprioception: Joint position sense at toes, fingers
    • Cortical sensation: Two-point discrimination, graphesthesia, stereognosis (if indicated)
    • Document sensory level if present
    • Note distribution: dermatomal, stocking-glove, hemibody, etc.

  7. Reflexes:

    • Graded 0-4+ for each reflex bilaterally:
      • 0: Absent
      • 1+: Trace or diminished
      • 2+: Normal
      • 3+: Increased
      • 4+: Hyperactive with clonus
    • Deep tendon reflexes: Biceps (C5-6), triceps (C7-8), brachioradialis (C5-6), patellar (L3-4), Achilles (S1-2)
    • Plantar response: Flexor (normal) or extensor/Babinski (abnormal)
    • Jaw jerk: If indicated (hyperreflexia suggests upper motor neuron lesion above C5)

  8. Coordination:

    • Finger-to-nose testing: Smooth vs dysmetric, tremor
    • Heel-to-shin testing: Smooth trajectory
    • Rapid alternating movements: Hand patting, finger tapping
    • Fine motor: Writing, buttoning if indicated
    • Document as normal, dysmetria, intention tremor, or dysdiadochokinesia

  9. Gait and Station:

    • Station: Romberg test (eyes open then closed), postural stability
    • Gait: Normal base, stride length, arm swing, speed
    • Tandem gait: Heel-to-toe walking
    • Special gaits: If present, describe (hemiplegic, ataxic, Parkinsonian, steppage, waddling, antalgic)
    • Assistive devices: Cane, walker, wheelchair
    • Falls: Falls attempted during exam

  10. Special Tests (as indicated):

    • Meningeal signs: Nuchal rigidity, Kernig sign, Brudzinski sign
    • Provocative maneuvers: Lhermitte sign, Spurling test, straight leg raise
    • Movement disorder examination: Tremor characteristics, bradykinesia, rigidity assessment

  11. Assessment Scales (as applicable):

    • NIH Stroke Scale (NIHSS) for stroke
    • Modified Rankin Scale (mRS) for functional outcome
    • Montreal Cognitive Assessment (MoCA) or MMSE for cognition
    • UPDRS for Parkinson's disease
    • Seizure frequency log
    • Headache diary review

Example Objective Section for Neurology

Objective (O)
 
 
Vital Signs:
BP 152/88 mmHg, HR 76 bpm regular, RR 14, Temp 98.2°F, SpO2 98% on room air, Weight 165 lbs
 
General:
Alert, cooperative, well-appearing, no acute distress
 
Mental Status:
- Alert and oriented to person, place, time, and situation
- Attention: Serial 7s performed accurately
- Memory: 3/3 word recall at 5 minutes
- Language: Fluent speech, intact comprehension, repetition, and naming
- MoCA: 28/30 (lost 1 point on delayed recall, 1 point on abstraction)
 
Cranial Nerves:
- CN II: Visual acuity 20/25 OU with glasses, visual fields full by confrontation, fundi show sharp disc margins without papilledema
- CN III, IV, VI: Pupils 3mm, equal, round, reactive to light and accommodation. Extraocular movements intact, no nystagmus, no ptosis
- CN V: Facial sensation intact to light touch V1-V3 bilaterally, jaw strength normal
- CN VII: Facial strength symmetric, no facial droop
- CN VIII: Hearing grossly intact bilaterally
- CN IX, X: Palate elevates symmetrically, gag reflex present
- CN XI: Shoulder shrug and head turn strength 5/5 bilaterally
- CN XII: Tongue protrudes midline, no fasciculations
 
Motor:
- Bulk: Mild atrophy of intrinsic foot muscles bilaterally
- Tone: Normal throughout
- Strength:
- Upper extremities: 5/5 throughout (deltoids, biceps, triceps, wrist extensors/flexors, finger flexors/extensors/abductors) bilaterally
- Lower extremities:
* Iliopsoas 5/5 bilaterally
* Quadriceps 5/5 bilaterally
* Hamstrings 5/5 bilaterally
* Dorsiflexors 4+/5 bilaterally
* Plantarflexors 5/5 bilaterally
- No pronator drift
- No fasciculations
 
Sensory:
- Light touch: Decreased below ankles bilaterally in stocking distribution
- Pinprick: Decreased below ankles bilaterally in stocking distribution
- Vibration: Absent at great toes bilaterally, decreased at medial malleoli, present at patellae
- Proprioception: Impaired at great toes bilaterally, intact at ankles
- Romberg: Positive (increased sway with eyes closed, near-fall caught by examiner)
 
Reflexes:
Biceps Triceps Brachiorad Patellar Achilles
Right 2+ 2+ 2+ 2+ 1+
Left 2+ 2+ 2+ 2+ 1+
Plantar responses: Flexor bilaterally
 
Coordination:
- Finger-to-nose: Intact bilaterally without dysmetria
- Heel-to-shin: Intact bilaterally
- Rapid alternating movements: Normal bilaterally
 
Gait and Station:
- Romberg: Positive as above
- Gait: Broad-based, cautious, slow. Decreased stride length. Uses walls for support
- Tandem gait: Unable to perform due to imbalance
- Patient uses single-point cane for ambulation
 
Diagnostic Studies (available for review):
- HbA1c 3 weeks ago: 8.2%
- Basic metabolic panel 3 weeks ago: Creatinine 1.1 mg/dL, eGFR 68 mL/min
 

Assessment Section (A)

The Assessment section synthesizes subjective and objective findings into a clinical impression, with differential diagnosis when appropriate.

Assessment Section (A) Components

  1. Primary Diagnosis:

    • Most likely neurological diagnosis based on presentation
    • ICD-10 code when documenting
    • Localization (anatomical localization of lesion if applicable)
    • Example: "Diabetic peripheral polyneuropathy with sensory ataxia"

  2. Secondary Diagnoses:

    • Other active neurological conditions
    • Relevant comorbidities affecting neurological care
    • Risk factors

  3. Clinical Reasoning:

    • Support for your primary diagnosis
    • Key findings that point to diagnosis
    • Differential diagnoses considered
    • Findings that rule out alternative diagnoses

  4. Severity Assessment:

    • Mild, moderate, or severe
    • Functional impact quantified
    • Progression (stable, improving, worsening)
    • Disability level if applicable (Modified Rankin Scale, EDSS, etc.)

  5. Complications or Risks:

    • Fall risk
    • Seizure risk
    • Stroke risk
    • Medication side effects
    • Need for monitoring

Example Assessment Section for Neurology

Assessment (A)
 
 
1. Diabetic peripheral polyneuropathy, moderate severity, with sensory ataxia
- Clinical presentation consistent with length-dependent sensory polyneuropathy
- Examination shows stocking distribution sensory loss to ankles bilaterally
- Absent vibration sense at toes, impaired proprioception
- Positive Romberg sign indicates sensory ataxia
- Gait impairment and recurrent falls directly attributable to sensory deficits
- Suboptimal diabetes control (HbA1c 8.2%) is primary contributing factor
 
2. Type 2 diabetes mellitus, inadequately controlled (HbA1c 8.2%)
- Major risk factor for progression of neuropathy
- Requires intensification of glucose management
 
3. Hypertension, controlled on current medication
 
4. High risk for falls
- 4 falls in past 2 months
- Positive Romberg, gait instability, sensory ataxia
- Lives alone, which increases injury risk
 
Clinical Reasoning:
Patient presents with classic findings of diabetic peripheral neuropathy: symmetric distal sensory loss in stocking distribution, impaired vibration and proprioception, diminished ankle reflexes, and mild foot intrinsic muscle atrophy. The positive Romberg sign indicates that she relies heavily on vision to compensate for impaired proprioception, explaining why balance worsens in the dark. The duration of diabetes (12 years), poor recent glucose control, and absence of other neuropathy causes (no alcohol abuse, no B12 deficiency risk factors, not on medications causing neuropathy) support diabetic etiology.
 
Alternative diagnoses considered but less likely:
- Cervical myelopathy: Would expect upper motor neuron signs (hyperreflexia, Babinski signs), upper extremity involvement, and neck pain - all absent
- Vitamin B12 deficiency: Would expect macrocytic anemia, possible cognitive changes, and hematologic abnormalities - patient on metformin but no MCV elevation noted
- Spinal stenosis: Would expect positional symptoms (neurogenic claudication), back pain, and improvement with rest - not consistent with patient's presentation
- Vestibular disorder: Would expect vertigo, nystagmus - not present
 
Prognosis:
Diabetic neuropathy is typically slowly progressive. With improved glucose control, further progression may be slowed, and neuropathic pain may improve with appropriate treatment. However, established sensory deficits are unlikely to fully reverse. Fall risk is high and requires aggressive intervention. Functional independence is at risk if falls continue.
 

Plan Section (P)

The Plan section outlines diagnostic testing, therapeutic interventions, patient education, and follow-up strategy.

Plan Section (P) Components

  1. Diagnostic Testing:

    • Laboratory studies
    • Neuroimaging (MRI, CT, CTA, MRA)
    • Electrodiagnostic studies (EMG/NCS)
    • EEG for seizures
    • Lumbar puncture if indicated
    • Neuropsychological testing

  2. Medications:

    • New prescriptions with indication, dose, frequency
    • Medication changes or discontinuations
    • Monitoring requirements (labs, levels, side effects)

  3. Therapeutic Interventions:

    • Physical therapy referrals
    • Occupational therapy referrals
    • Speech therapy referrals
    • Other subspecialty consultations

  4. Lifestyle and Risk Factor Modification:

    • Diet and exercise recommendations
    • Smoking cessation
    • Alcohol reduction
    • Sleep hygiene
    • Stress management

  5. Patient Education:

    • Explanation of diagnosis in layman's terms
    • Natural history and prognosis
    • Warning signs to watch for
    • When to seek emergency care
    • Medication instructions and side effects
    • Fall prevention strategies

  6. Safety Planning:

    • Fall prevention measures
    • Driving restrictions if applicable
    • Seizure precautions
    • Home safety evaluation

  7. Follow-Up:

    • Next appointment timing and purpose
    • Monitoring plan
    • Goals for next visit
    • Contingency plans if symptoms worsen

Example Plan Section for Neurology

Plan (P)
 
 
1. Diabetic Peripheral Polyneuropathy:
 
Diagnostic Testing:
- EMG/nerve conduction studies to confirm diagnosis and assess severity (ordered, scheduled for 2 weeks)
- Vitamin B12 level to rule out B12 deficiency (lab order given)
- TSH to rule out thyroid disorder (lab order given)
- Fasting lipid panel (lab order given)
- Comprehensive metabolic panel to assess renal function (lab order given)
 
Medications for Neuropathic Pain (if patient develops pain):
- Will consider gabapentin or duloxetine if neuropathic pain develops
- Patient currently denies significant neuropathic pain
 
Non-Pharmacologic Management:
- Physical therapy referral for gait training, balance exercises, and assistive device assessment
- Occupational therapy referral for home safety evaluation and ADL optimization
- Consider referral to podiatry for diabetic foot care
 
2. Diabetes Management:
 
Medication Changes:
- Discussed with patient need to intensify diabetes management
- Will coordinate with PCP to uptitrate metformin to 1000 mg three times daily if tolerated
- Consider addition of GLP-1 agonist or SGLT-2 inhibitor
- Target HbA1c <7% to slow neuropathy progression
 
Monitoring:
- Repeat HbA1c in 3 months
- Home glucose monitoring recommended
 
Patient Education:
- Explained connection between blood sugar control and neuropathy
- Emphasized importance of medication adherence and lifestyle modifications
 
3. Fall Prevention:
 
Safety Interventions:
- Home safety evaluation by OT (ordered)
- Consider grab bars in bathroom, improved lighting, removal of tripping hazards
- Patient currently using single-point cane - PT to assess if four-wheeled walker more appropriate
 
Activity Modifications:
- Avoid walking in dark or on uneven surfaces without assistance
- Use assistive lighting at night
- Consider medical alert system given high fall risk and living alone
 
Driving:
- Discussed driving safety concerns given impaired proprioception and recent falls
- Recommend evaluation by driving rehabilitation specialist
- Consider alternative transportation options
 
4. Patient Education Provided:
 
Diagnosis Explanation:
- Explained that diabetes has caused nerve damage in feet and legs
- Nerve damage affects ability to feel position of feet, causing balance problems
- This is why balance is worse in dark (can't see to compensate for lost feeling)
 
Prognosis:
- Nerve damage typically does not fully reverse
- Better blood sugar control can slow or stop progression
- Medications can help if pain develops
- Physical therapy can improve balance and reduce fall risk
- With good management and safety precautions, can maintain independence
 
Warning Signs:
- Instructed to call or go to ER if develops sudden weakness, foot ulcers, severe pain, or inability to walk
 
Fall Prevention Education:
- Discussed importance of using assistive device consistently
- Avoid rushing, especially when getting up at night
- Turn on lights before walking
- Use handrails on stairs
- Wear supportive shoes with non-slip soles
- Consider hip protectors
 
5. Coordination of Care:
 
- Will send consultation note to PCP requesting diabetes management intensification
- Will communicate PT/OT findings and recommendations
- Patient to follow up with PCP within 2 weeks for diabetes management
 
6. Follow-Up Plan:
 
- Return to neurology clinic in 4-6 weeks (after EMG and labs completed)
- Goals for next visit:
* Review EMG/NCS results
* Review laboratory results and address any abnormalities
* Assess response to PT/OT interventions
* Evaluate fall frequency since interventions
* Reassess need for neuropathic pain medication
* Check HbA1c improvement
- Patient instructed to call sooner if symptoms worsen, new symptoms develop, or additional falls occur
- Patient verbalized understanding of plan and agreed to recommendations
 
7. Prescriptions and Orders Given Today:
 
- EMG/nerve conduction studies (scheduled)
- Physical therapy evaluation and treatment (up to 12 visits)
- Occupational therapy home safety evaluation
- Laboratory studies: Vitamin B12, TSH, fasting lipid panel, comprehensive metabolic panel, HbA1c
- Neurology follow-up in 4-6 weeks (appointment scheduled)
 

AI-Assisted Documentation for Neurology

AI documentation tools can significantly reduce charting burden for neurologists, but require careful oversight given the complexity and precision required in neurological documentation.

How AI Can Help with Neurology Notes

  • Ambient capture: Records patient history and neurological symptoms during the encounter
  • Exam structuring: Organizes neurological exam findings into standardized format
  • Terminology: Captures medical and neurological terminology accurately
  • Time savings: Reduces documentation time by 50-70% according to recent studies

Neurology-Specific AI Considerations

What AI Captures Well:

  • Patient-reported symptoms and history
  • Medication lists and allergies
  • Previous medical history
  • Patient questions and concerns
  • Treatment plan discussion

What Requires Careful Review:

  • Laterality (left vs right) - critically important in neurology
  • Neurological exam findings - strength grades, reflex grades, specific cranial nerve findings
  • Anatomical localization - ensure terms like "left MCA territory" or "C7 dermatome" are correct
  • Assessment scales - verify NIHSS scores, MoCA scores, etc. are accurately captured
  • Differential diagnosis reasoning - AI may not capture your clinical thinking
  • Urgent findings - ensure critical findings like acute stroke are prominently documented

Tips for Using AI with Neurology Documentation

  1. Verbalize laterality clearly: "Left arm strength is 4 out of 5, right arm is 5 out of 5"
  2. State findings explicitly: "Babinski sign is present on the right, flexor response on the left"
  3. Dictate exam structure: Follow SOAP format verbally during your exam
  4. Review carefully: Always verify neurological exam findings, especially laterality and specific grades
  5. Add clinical reasoning: AI captures conversations but may miss your diagnostic thought process

For more details, see our AI-Assisted Documentation Guide.

Telehealth Neurology Documentation

Telehealth has limitations for neurology given the importance of hands-on examination, but is valuable for follow-ups, medication management, and some consultations.

Appropriate Telehealth Uses in Neurology

  • Medication management for stable conditions
  • Follow-up for chronic neurological disorders
  • Seizure frequency review and medication adjustments
  • Headache follow-ups
  • Initial consultations (with plan for in-person exam)
  • Parkinson's disease medication adjustments (can observe movements)
  • Cognitive screening

Telehealth Limitations in Neurology

Critical Limitations to Document:

  • Cannot perform hands-on neurological examination
  • Unable to assess muscle tone, reflexes, sensory function
  • Limited assessment of coordination and gait (dependent on camera view and patient ability)
  • Cannot perform fundoscopy or detailed cranial nerve exam
  • Stroke evaluation requires in-person assessment

Example Telehealth Neurology Documentation

Telehealth Neurology Visit Example
 
 
TELEHEALTH SESSION DETAILS:
- Platform: Zoom for Healthcare (HIPAA-compliant)
- Patient Location: Home in [State]
- Provider Location: [State]
- Consent: Patient verbally consented to telehealth neurology visit
- Technical Quality: Good video and audio quality throughout visit
 
OBJECTIVE (Modified for Telehealth):
- Mental Status: Alert, oriented x3, appropriate conversation, no obvious cognitive impairment
- Speech: Fluent, no dysarthria observed
- Cranial Nerves (limited exam):
* CN II: Patient able to see small print on screen at reasonable distance
* CN III, IV, VI: Extraocular movements appear full, no obvious ptosis
* CN VII: Facial symmetry preserved, no facial droop
* CN XII: Tongue protrusion midline
- Motor: Patient able to demonstrate arm movements, no obvious weakness or asymmetry. Able to stand from chair without difficulty (observed via video).
- Gait: Patient walked across room - gait steady, normal stride, good arm swing bilaterally
 
TELEHEALTH LIMITATIONS DOCUMENTED:
Unable to perform via telehealth: muscle tone assessment, precise strength testing, sensory examination, reflex testing, cerebellar testing, fundoscopic examination, or detailed cranial nerve testing. This visit limited to visual observation of gross movements, mental status assessment, and medication management. In-person comprehensive neurological examination planned if clinically indicated based on symptom changes.
 
PLAN:
- Continue current medication regimen for Parkinson's disease
- Schedule in-person visit in 3 months for complete neurological examination
- Patient to call immediately if develops new or worsening symptoms requiring urgent evaluation
 

For complete telehealth neurology guidance, see our Telehealth SOAP Notes Guide.

Related SOAP Note Guides

Frequently Asked Questions

Document the complete neurological exam systematically: mental status (orientation, memory, attention), cranial nerves (I-XII with specific findings), motor exam (strength graded 0-5/5 for each muscle group, tone, bulk), sensory exam (light touch, pain, vibration, proprioception), reflexes (graded 0-4+ with location), coordination (finger-to-nose, heel-to-shin, rapid alternating movements), and gait assessment. Be specific about laterality (left vs right) and anatomical distribution of findings.

Common neurology assessment scales include: NIH Stroke Scale (NIHSS) for acute stroke, Modified Rankin Scale (mRS) for functional outcomes, Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam (MMSE) for cognitive function, Unified Parkinson's Disease Rating Scale (UPDRS) for Parkinson's disease, Expanded Disability Status Scale (EDSS) for multiple sclerosis, and various seizure frequency tracking measures. Document both the score and clinical significance.

For seizure documentation, include: seizure type and classification (focal vs generalized), detailed description of semiology (aura, motor manifestations, loss of awareness, post-ictal period), duration, frequency (daily, weekly, monthly), last seizure date, triggers identified, impact on daily activities, medication adherence and levels, previous seizure types, and any changes in pattern. Include witness descriptions when available and any video recordings reviewed.

Document headache characteristics using POUND or similar mnemonics: Pulsating quality, One day duration (4-72 hours for migraine), Unilateral location, Nausea/vomiting, Disabling intensity. Include frequency, triggers, aura symptoms, associated symptoms (photophobia, phonophobia), pain intensity (0-10 scale), functional impact, previous treatments tried and response, medication overuse assessment, and red flags ruled out (thunderclap onset, neurological deficits, fever, etc.).

For stroke documentation, include: onset time (exact time when patient was last known well - critical for treatment decisions), NIH Stroke Scale score with subscores, vascular territory affected, imaging findings (CT or MRI), vessel occlusion if present, hemorrhage vs ischemic determination, risk factors (atrial fibrillation, hypertension, diabetes, etc.), functional baseline pre-stroke, thrombolysis or thrombectomy eligibility and decisions, and discharge planning with Modified Rankin Scale score.

For movement disorders like Parkinson's disease, document: specific movement abnormality type (tremor, rigidity, bradykinesia, dyskinesia, chorea, ataxia), laterality and body distribution, timing (resting vs action, constant vs intermittent), severity using standardized scales (UPDRS for Parkinson's), impact on activities of daily living, medication response ('on' vs 'off' states), motor complications (wearing off, dyskinesias), and functional mobility assessment including falls history.

Yes! AI tools like SOAPNoteAI.com can significantly reduce documentation time for neurology notes. The AI can capture detailed neurological exam findings, format assessments with proper laterality and anatomical terms, and structure complex neurology encounters. However, always carefully review AI-generated notes for accuracy of neurological terms, laterality (left vs right), specific findings like strength grades and reflex scores, and clinical reasoning for diagnoses and treatment plans.

Medical Disclaimer: This content is for educational purposes only and should not replace professional medical judgment. Always consult current clinical guidelines and your institution's policies.

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