Neurology Inpatient Progress Note

Date/Time: [Date and time of note entry]

Hospital Day: [Hospital day number]

Provider: [Name, credentials]

Attending: [Name, credentials]

One-Liner

[Single-sentence orientation including age, primary neurologic diagnosis, key context/comorbidity, hospital day, current status: [improving / worsening / stable], and critical supports or complications if relevant]

Interval Events

(Summarize overnight and interval events relevant to today's decisions. Label sources: patient report, RN, therapy, family, chart review. If no acute events, explicitly document after verification.)

• Neuro-specific events: [New deficits, seizures, mental status changes, ICP/CPP concerns, sedation changes, treatments given affecting today's exam]
• Systemic events impacting neuro care: [BP/oxygenation episodes, fever, procedures, hemodynamic changes relevant to cerebral perfusion]
• Patient-reported symptoms: [Symptoms if obtainable] (If unable to participate, state why and note alternative source.)
• Nursing/Therapy updates: [Neuro checks trend, safety events, swallow status, mobility findings, therapy recommendations]

Objective

Vitals: [Neurologically relevant ranges and trends relative to goals; include ICP/CPP if applicable; telemetry or glucose extremes only if neurologically relevant]

General Exam: [Appearance, perfusion, respiratory status, and other pertinent findings relevant to cerebral perfusion/oxygenation]

Neuro Exam: (Document only what was actually examined today. Do not mark normal/intact unless explicitly examined. If a component cannot be assessed, state the reason. Note confounders such as sedation, encephalopathy, or baseline deficits with timing.)

• Mental status/LOC: [Alertness, orientation, attention, command following]
• Speech/Language: [Fluency, comprehension, naming, repetition, dysarthria] (Note limitations such as airway devices.)
• Cranial nerves: [Nerves and functions actually tested with pertinent findings]
• Motor: [Tone, strength with stated grading convention, drift, asymmetries]
• Sensory: [Modalities tested and distribution] (Note reliability/confounders.)
• Reflexes: [DTRs, plantars, clonus as examined] (Include only if clinically relevant today.)
• Coordination: [Tests performed and results] (Note if limited by weakness.)
• Gait/Station: [Assessed / Deferred: [reason]] (Include assistive devices or safety concerns.)
• NIHSS: [Score] (Include for stroke patients if used by service; note trend from prior.)

Data: (Include only interval results since last note affecting today's decisions. Use trend language. For pending results, state clinical decision contingent upon them.)

• Labs: [Key neuro-relevant values with trends: Na, osms, glucose, CBC, coagulation, inflammatory markers as relevant]
• Imaging/Neurodiagnostics: [CT/MRI/CTA findings; EEG trends; ICP data; TCDs; other studies as relevant] (Summarize critical findings and changes.)

Key Meds: [Relevant starts/stops/adjustments in antithrombotics, antiseizure meds, sedatives, steroids, osmotherapy, and other high-risk neuro medications]

Assessment/Plan

(Problem-oriented format ordered by clinical priority: life-threatening or unstable issues first, then active neurologic problems, then systemic issues affecting neuro care. Include only problems relevant today.)

[Problem 1]: [Diagnosis or clinical issue]

Assessment: [Current status with key supporting data or exam change]

Plan: [Today's diagnostics, therapeutics, consults; monitoring parameters with explicit goals (BP/Na/ICP targets, neuro check frequency); contingencies and escalation triggers; nursing instructions and precautions; therapy coordination; family communication; disposition planning as relevant]

[Problem 2]: [Diagnosis or clinical issue]

(Repeat structure for additional active problems.)

Assessment: [Current status]

Plan: [Actions, monitoring, contingencies as relevant]

(Avoid copy-forward; verify each element reflects today's clinical reality. For expected exam components not evaluated, document reason.)