TITLE: GUIDELINE FOR 24 HOUR NEUROLOGICAL/NEUROVASCULAR FLOW SHEET

1. GUIDELINE FOR 24 HOUR NEUROLOGICAL FLOW SHEET

PURPOSE: This Neurological Assessment is charted using numbers, letters, and symbols. Please refer to the key for these symbols.

When the patient’s assessment does not meet the predetermined neurological criteria, place a star, (*) next to the number, letter, or symbol in that category. A star (*) indicates a change. A change in the patient’s condition requires a focus note. For subsequent assessments, an arrow (® ) is used to indicate that the assessments continue unchanged.

INSTRUCTIONS:

1. Affix patient identification.
2. Write in date.
3. Indicate frequency (e.g. q4 hrs.). 3a. Indicate the time the assessment is done.
4. Eyes: Write in the number that correlates with key.
5. Motor: Same as #4
6. Verbal: Same as #4

Pupils:

7. Right: Write in the number and symbol that correlate with the key.
8. Left: Same as #7

Extremities:

9. RA: Write in the letter and/or symbol that correlates.
10. LA: Same as #9
11. RL: Same as #9
12. LL: Same as #9
13. Initial the bottom of the assessment column and in the small box preceding the Nurse’s signature.
14. Enter legible signature and title of staff who have initialed the assessment sheet.

Focus Note: Each focus note needs to be timed and initialed. Only focus notes pertaining to neurological/vascular assessments are to be recorded on this form. All other focus notes and "E" notes are documented on the 24 Hour Flow Sheet.

15. Enter time of assessment.
16. *Note.

2. GUIDELINE FOR 24 HOUR NEUROVASCULAR FLOW SHEET

This form is used for frequent, specific, neurovascular assessments. The assessments are charted using letters and symbols. Please refer to the bottom of the neurovascular page for the key.

INSTRUCTIONS:

1. Affix patient identification to the top of the Neurological Assessment page.
2. Write in date.
3. Write in procedure/diagnosis.
4. Write in location of area to be assessed.

1. Note frequency ordered.

e.g.: #1 Right neck Checks: q 2hrs. x 4 q 4hrs. x 2
        #2 Left leg Checks: q 2hrs. x 8 q 4hrs. x 2

5. Indicate specific parameters ordered by the doctor.

e.g.: Call for Laser doppler < 10 for 15 minutes.

6. Initials
7. Enter correlating legible signature and title of staff who initialed the assessment sheet.
8. Enter initials of the assessor.
9. Write time of assessment.
10. 1Note location number that is being assessed.
11. 1Place a letter or symbol next to all the categories that apply to the assessed area.
12. Utilize blanks to write in additional criteria that must be assessed but is not listed.

When the patient’s neurovascular assessment demonstrates a change and/or an abnormal finding, place a star (*) next to the letter/symbol in that category. A * indicates a change. A change in the patient’s condition requires a focus note.

For subsequent assessments, an arrow (® ) cannot be utilized if multiple locations are being charted.

Focus Notes are located at the bottom of the Neurological Assessment page. Each focus note must be timed and initialed. Only focus notes pertaining to neurological/neurovascular assessments are to be recorded on this form. All other focus notes and "E" notes are documented on the 24 Hour Flow Sheet.

RESOURCE PERSON(S): Denise Webb, RN; Lori Frazier, RN; Toni Saunders, RN

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