Spinal Cord Injury ASIA Exam Documentation

Document motor, sensory, and anal exam findings to classify the ASIA Impairment Scale grade and neurological level, establishing a spinal cord injury severity baseline.

Exam Context

• Exam Date
• Exam Time
• Exam Type
• Injury Context
  Briefly describe the known or suspected spinal cord injury context and relevant clinical situation.
• Exam Performed By
  Clinician name and credentials.
• Patient Consent / Disclosure

Motor Examination

• Motor Exam Completed
• Right Upper Extremity Motor Score
  Enter the summed motor score for the right upper extremity when applicable.
• Left Upper Extremity Motor Score
  Enter the summed motor score for the left upper extremity when applicable.
• Right Lower Extremity Motor Score
  Enter the summed motor score for the right lower extremity when applicable.
• Left Lower Extremity Motor Score
  Enter the summed motor score for the left lower extremity when applicable.
• Motor Exam Notes
  Document key asymmetries, pain-limited effort, or other factors affecting interpretation.

Sensory Examination

• Sensory Exam Completed
• Light Touch Status
• Pin Prick Status
• Right Sensory Level
  Document the most caudal intact sensory level on the right, if determined.
• Left Sensory Level
  Document the most caudal intact sensory level on the left, if determined.
• Sensory Exam Notes
  Include any exam limitations, inconsistent responses, or factors affecting reliability.

Sacral Sparing and Anal Examination

• Sacral Sparing Present
• Deep Anal Pressure
• Voluntary Anal Contraction
• Anal Exam Notes
  Document patient tolerance, exam limitations, or reasons the exam could not be completed.

Classification and Interpretation

• Neurological Level of Injury
  Enter the determined neurological level of injury.
• ASIA Impairment Scale Grade
• Classification Rationale
  Summarize the findings used to determine the neurological level and ASIA grade.
• Baseline Established

Follow-Up and Submission

• Follow-Up Plan
  Document recommended repeat exam timing, specialist review, or rehabilitation follow-up.
• Handoff Required
• Handoff Notes
  Visible when a handoff is needed; include concise clinical summary for the receiving team.