AreaCriticalElement
Assessment QuestionstoAsk Normal
Findings
Could you please
provide your full name
and date of birth?
Do you have any
allergies to
medications, latex, or Patient agrees
Introduce self, verify
foods? to assessment,
Introduction / patient, explain
appears
Universal procedure, provide Are you in any pain
comfortable
privacy, hand hygiene. right now?
and oriented.
Do you need to use the
restroom?
Do you need
assistance with daily
activities?
Alert, calm,
appropriate
1. Assess mental status
responses.
(appearance, behavior,
Oriented to
cognition, thought
process). Can you tell me your person, place,
time, and
name, where you are, event.
today’s date, and why
2. Assess orientation
you’re here?
(person, place, time, Oriented ×4.
event).
Follows
3. Assess response to
commands
simple commands.
appropriately.
Touch your finger to
Neurological / 5. Assess coordination & Smooth,
Sensory skilled movement. your nose, then my coordinated.
finger.
6. Assess balance & gait. Please walk to the doorSteady gait,
upright
and back.
posture.
Tell me when you feel
this. (use Qtips to Intact
7. Assess sensation
touch face, upper sensation
(face, UE, LE bilaterally).
extremities, lower bilaterally.
extremities)
4. Assess UE- ask the patient to
Strong, equal
voluntary/involuntary squeeze hand, push
bilaterally.
motor response (UE/LE). against resistant of my
, hands, LE- push your
feet dow like pressing
the gas, bend toes
upward ; Test each
reflex sites for
8. Assess reflexes: 2+ bilaterally.
involuntary response
(biceps, triceps,
brachioradialis,
quadriceps, Achilles,
plantar.)
CN I – Olfactory: Test Close one eye, occlude Correctly
identifies scent
smell with familiar scent, one nostril, sniff and
bilaterally. CN I
one nostril at a time. identify scent.
intact
Patient was
CN II – Optic: Test visual
acuity, visual fields, Ask patient to read able to read
your badge badge, CN II
inspect optic disc.
intact
Smooth eye
movements,
Follow mypen with your
CN III, IV, VI – pupils equal
eyes only. Shine a light
Oculomotor, Trochlear, round reactive
on the eyes. Six
Abducens: Test EOMs, to light with
cardinal fields of gaze,
PERRLA. accommodatio
pupils for size/reaction.
n. CNIII, IV, VI
intact
Clench teeth; tell me
when you feel the
Strong, equal
cotton touch on
CN V – Trigeminal: Test bite; sensation
forehead, cheek, chin.
motor (jaw strength) and intact in all
sensory (light touch). Landmark: divisions. CN V
Temporal/masseter
intact.
muscles; facial
dermatomes.
Movements
Smile, frown, close
CN VII – Facial: Test symmetrical,
eyes tight, raise
facial movements. no weakness.
eyebrows, puff cheeks.
CN VI intact
CN VIII – Repeats words
Cover one ear, repeat
Acoustic/Vestibulocochle correctly
whispered words. Ear
ar: Test hearing (whisper canal proximity ~2 feet. bilaterally. CN
test). VIII intact
CN IX, X – Say 'ahh' and swallow. Palate rises
Glossopharyngeal & Check for movement of midline, uvula
Vagus: Test palate rise, palate. Landmark: Soft midline, voice
gag reflex, voice. palate, uvula, gag clear. CN IX, X
Assessment QuestionstoAsk Normal
Findings
Could you please
provide your full name
and date of birth?
Do you have any
allergies to
medications, latex, or Patient agrees
Introduce self, verify
foods? to assessment,
Introduction / patient, explain
appears
Universal procedure, provide Are you in any pain
comfortable
privacy, hand hygiene. right now?
and oriented.
Do you need to use the
restroom?
Do you need
assistance with daily
activities?
Alert, calm,
appropriate
1. Assess mental status
responses.
(appearance, behavior,
Oriented to
cognition, thought
process). Can you tell me your person, place,
time, and
name, where you are, event.
today’s date, and why
2. Assess orientation
you’re here?
(person, place, time, Oriented ×4.
event).
Follows
3. Assess response to
commands
simple commands.
appropriately.
Touch your finger to
Neurological / 5. Assess coordination & Smooth,
Sensory skilled movement. your nose, then my coordinated.
finger.
6. Assess balance & gait. Please walk to the doorSteady gait,
upright
and back.
posture.
Tell me when you feel
this. (use Qtips to Intact
7. Assess sensation
touch face, upper sensation
(face, UE, LE bilaterally).
extremities, lower bilaterally.
extremities)
4. Assess UE- ask the patient to
Strong, equal
voluntary/involuntary squeeze hand, push
bilaterally.
motor response (UE/LE). against resistant of my
, hands, LE- push your
feet dow like pressing
the gas, bend toes
upward ; Test each
reflex sites for
8. Assess reflexes: 2+ bilaterally.
involuntary response
(biceps, triceps,
brachioradialis,
quadriceps, Achilles,
plantar.)
CN I – Olfactory: Test Close one eye, occlude Correctly
identifies scent
smell with familiar scent, one nostril, sniff and
bilaterally. CN I
one nostril at a time. identify scent.
intact
Patient was
CN II – Optic: Test visual
acuity, visual fields, Ask patient to read able to read
your badge badge, CN II
inspect optic disc.
intact
Smooth eye
movements,
Follow mypen with your
CN III, IV, VI – pupils equal
eyes only. Shine a light
Oculomotor, Trochlear, round reactive
on the eyes. Six
Abducens: Test EOMs, to light with
cardinal fields of gaze,
PERRLA. accommodatio
pupils for size/reaction.
n. CNIII, IV, VI
intact
Clench teeth; tell me
when you feel the
Strong, equal
cotton touch on
CN V – Trigeminal: Test bite; sensation
forehead, cheek, chin.
motor (jaw strength) and intact in all
sensory (light touch). Landmark: divisions. CN V
Temporal/masseter
intact.
muscles; facial
dermatomes.
Movements
Smile, frown, close
CN VII – Facial: Test symmetrical,
eyes tight, raise
facial movements. no weakness.
eyebrows, puff cheeks.
CN VI intact
CN VIII – Repeats words
Cover one ear, repeat
Acoustic/Vestibulocochle correctly
whispered words. Ear
ar: Test hearing (whisper canal proximity ~2 feet. bilaterally. CN
test). VIII intact
CN IX, X – Say 'ahh' and swallow. Palate rises
Glossopharyngeal & Check for movement of midline, uvula
Vagus: Test palate rise, palate. Landmark: Soft midline, voice
gag reflex, voice. palate, uvula, gag clear. CN IX, X
