Sample neurological assessment documentation
[DOC File]Head-to-Toe Narrative Assessment Example
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Head-to-Toe Narrative Assessment Example Note: this sample charting was from a patient with a recent CVA. The areas of assessment you need to focus on depend on what is wrong with your particular patient. 10/4/96 2100. 86 y.o. male admitted 10/3/96 for L CVA. V/S 99.2 T, 100, 20, 140/76. Vital signs assessed q 2 hrs, Nursing Assessments every 4 ...
[DOC File]01 – Report Template Initial Assessments
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Assessment of Interests, Aptitudes and Abilities . The report will identify the assessment instruments used, state the results, and provide impressions of the Veteran’s vocationally significant personality traits. Assessment results will be used during the rehabilitation planning process to identify the need for remediation or basic skills.
[DOC File]MUSCULOSKELTAL SAMPLE WRITE-UP
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MUSCULOSKELTAL SAMPLE WRITE-UP. Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case.
[DOC File]Examiner’s Records for Dyslexia
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When the assessment is completed, you will be invited to attend a meeting to discuss the results and, should your child qualify for these services, to assist us in planning an individualized program. Attached is a pamphlet for your information titled “Notice of Parent …
[DOC File]Pre-Dive Checklist
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In the event of an injury, coordinate EMS response, treatment and consultation with EMS. If the injury is suspected to be hyperbaric related, EMS personnel should be provided with written documentation of the injured diver’s depth, down time, activity, initial complaints, neurological assessment findings, initial treatment and dive table status.
[DOC File]LAB 4: NEURO
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NEUROLOGICAL PHYSICAL EXAM. Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case. If no information was given in the case, assume a normal finding (i.e ...
[DOC File]Diagnosis in the Assessment Process
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Final Thoughts on DSM-5 in the Assessment Process. DSM-5 is one additional piece of the total assessment process. Along with the clinical interview, the use of tests, and informal assessment procedures, it can provide a broad understanding of the client and can be a critical piece in the treatment planning process.
[DOCX File]Facility Assessment Tool - SNFQAPI
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Facility Assessment Tool. Requirement. Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents (§483.70(e)). The requirement for the facility assessment may be found in Attachment 1. Purpose
[DOC File]SAMPLE EVALUATION FORM #1 - University of Pennsylvania
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This program met the stated objectives of: 1. Identify three types of neurological complications often found after traumatic brain injury. 2. Identify three types of other traumatic complications often found after traumatic brain injury. 3. List two types of medications to be avoided after traumatic brain injury. SPEAKERS (generally) 1.
[DOCX File]How to Use This Template - PointClickCare
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Sep 18, 2017 · This assessment asks you to collect and use information from a variety of sources. Some of the sources may include but are not limited to MDS reports, Quality Measures, 672 (Resident Census and Conditions of Residents) and/or 802 (Roster/Sample Matrix Form) reports, the Payroll-Based Journal, EHR reports and in-house designed reports.
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