Why generated normal text is safer than a macro

EHR macros paste a normal exam whether or not you examined it, and they bury the one abnormal finding in a wall of normal text. This generator does the reverse: it starts empty, writes normal only for systems you left untouched, and puts your abnormal finding first in each system's sentence. The result is a note that reads as examined.

The coma exam

Consciousness, brainstem reflexes, motor response, and respiration in the order the bedside exam proceeds, with the confounders line (sedation held, no paralytics, temperature) that a later reader — or a brain-death evaluation — will need. GCS is summed for you, including the T suffix for intubated patients.

Use it inside other notes

Paste the generated paragraph into the exam field of the consult builder or the objective section of any SOAP note in the residents' workspace.

Frequently asked questions

Does the generator ever write an abnormal finding I did not enter?

No. Every system prints normal unless you type something into it, and what you type is reproduced first, followed by the normal remainder. Gait can be marked normal, not tested for safety, or abnormal with your description.

Is the screening exam acceptable for documentation?

The screening variant omits the detailed sensory exam and is intended for follow-up notes and floor patients where a focused exam is appropriate; the full variant is for admissions and consults. Local documentation standards apply.

Can I document a brain-death exam here?

The coma variant covers the bedside components and the confounders line, but formal death-by-neurologic-criteria determination requires your institution's protocol and checklist, including apnea testing and prerequisites, which this generator does not replace.

References

  1. Campbell WW, Barohn RJ. DeJong's The Neurologic Examination. 8th ed. Wolters Kluwer; 2020.
  2. Greer DM, et al. Determination of brain death/death by neurologic criteria: the World Brain Death Project. JAMA. 2020;324:1078–1097.
  3. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–84.