comprehensive neurological examination in a child

How should a neurologist document a comprehensive neurological examination in a
an infant or small child where it is not possible to test orientation, knowledge, memory, speech, coordination, gait, etc???

Explain why not

The exam should be as comprehensive as possible- if the child cannot do the memory test, write "memory cannot be assessed due to age"- this will count.

Wasted time

Of course, the dilemma is, why are we being forced to waste time documenting the obvious. This serves no one. It only harms the physician, by causing unnecessary work, and secondarily harms the patient, by both taking time away from the doctor and by distracting the doctor from the many other points he/she needs to focus upon.

wasted time

I am sympathetic to your point of view.

In this case, you have two alternatives, neither perfect.

Bill based on time, if more than 50% was spent in discussion. You know the drill.

Do an eight organ system exam, which can be done without too much additional time. Here are my suggestions:

Constitutional (VSS, general appearance)
Eyes
Resp
Cardio
GI
Skin
Neuro
MS
Psych
(Is that eight?)

For the 1995 general multi-system exam, there is not a specific level of exam for each level. So you coudl say:

Vital signs normal, NAD
Eyes: conjunctiva normal, PERRLA
Lungs clear
RRR
Abd soft
Skin warm and dry
Neuro: I'll leave this to you
MS: also to you, I assume relevant
Psych: alert, anxious, etc.

The 1995 multi-system exam can be performed and documented fairly quickly so you can reach a comprehensive exam.