Neurology software: from the neurological examination to the neurosurgical operative note
Neurology software has to hold an examination that is mostly comparison: right against left, this month's power against last month's. This guide sets out what the record should contain, follows a clinic visit and a neurosurgical case in OPALEVI, and says what is left to you.
Key takeaways
- Record the examination as grids by side: cranial nerves, tone, MRC power, reflexes and the plantar response, each with a right and a left column.
- A score should keep its parts. In OPALEVI the GCS is entered as its three responses and the total is added up; mRS and Karnofsky are grades you enter.
- Neurosurgery needs a record of what happened in theatre: the lesion, the craniotomy, the implant with its batch, the instructions given at discharge.
- OPALEVI records and prints. Only the GCS is calculated, nothing is flagged, and no post-operative advice is written for you.
When neurological notes outgrow a paragraph
A normal examination fits on one line. Trouble starts when something is abnormal and the patient keeps returning:
- Sides vanish. “Weak leg” does not say which leg.
- Grades become adjectives. A power of 4 turns into “mild weakness”, and a later 3 into “still weak”.
- The GCS has no parts. A 10 in the notes cannot be checked: which response was lost?
- The operation leaves no trail. The implant's batch sits on a sticker in the theatre book, not in the patient's file.
Neurology is read side against side and visit against visit; a record that cannot be compared is only a diary.
What a neurology and neurosurgery record should hold
Before comparing programs, agree on what the record must contain. The list works on paper too:
| Field | Why it matters |
|---|---|
| Consciousness with its components | A GCS of 9 means little without the three responses that make it up. |
| Cranial nerves by side | Twelve rows, two columns: a facial weakness on the left is the finding itself. |
| Tone, power and reflexes by side | Numeric grades show an asymmetry at a glance and a change over time. |
| Plantar response | Flexor, extensor or absent on each side, in the same words each time. |
| Sensory findings with their dermatome | A level helps only if the area is named, not just shaded. |
| Function grades and seizure history | mRS or Karnofsky as the grade itself; when the last seizure was, and what happened. |
| For an operation: lesion, approach, implant, batch | What was found, where the skull or spine was opened, what was left behind. |
Record first, decide yourself
Software should keep what the examiner found and add up only what a scale says to add. What a GCS of 8 means for the plan is the clinician's call.
A neurology clinic visit in OPALEVI, step by step
An outpatient visit in the Neurology department: recurring headaches and tingling in one hand. Bold words are labels as the screen shows them.
Before the patient arrives
Reception books the slot with Add appointment; for a patient who wants one, it ticks Email the patient a reminder the day before. A nurse fills Vital signs and presses Mark ready for the doctor.
The narrative
The Doctor's report takes complaints, examination, diagnoses and advice. A new visit opens empty; earlier visits are listed in the patient file with their diagnosis and a short summary.
Consciousness
Under Consciousness, pick one response each for eye opening, verbal and motor in the Glasgow Coma Scale (GCS); the panel shows the total, the items answered and the 3–15 range.
The examination by side
Fill Cranial nerves by side, Muscle tone, Muscle power (MRC 0–5), Tendon reflexes (0–4) and the Plantar reflex, each with right and left columns, and notes beneath.
Maps, grades, paperwork
Mark the tingling on the Sensory map with its Dermatome, choose the Modified Rankin Scale (mRS) grade, complete Seizures if relevant, then write the Prescription or a Referral letter.
Neurology software tools: the GCS, grids by side and two maps
A GCS you can check
The scale goes in as eye opening 1–4, verbal 1–5 and motor 1–6. OPALEVI adds the three and prints the total with its responses and the University of Glasgow's credit: a sum, with no band or comment. Neurosurgery uses the same scale, so a GCS reads alike in both departments.
Grids that keep right and left apart
Each cranial nerve is normal, abnormal or Not tested on each side. Tone is chosen per upper and lower limb, up to spastic or rigid. Power covers eleven muscle groups in whole MRC grades, shoulder abduction plus the ten key muscles from elbow flexion to ankle plantar flexion, so a row also points to a root. Reflexes run 0–4 at five sites; the plantar response is flexor, Extensor (Babinski), equivocal or absent.
The brain, the spine and the skin
The Brain and spine map is a photographed brain from the left and a spine from the side, with lobes, cerebellum, brainstem and segments as regions; each mark takes a finding in words. On the Sensory map, a body figure with front, back, profile, face and hand views, each mark asks for a dermatome, V1–V3 down to S5, and the kind of change. You choose the dermatome; OPALEVI does not guess it.
The Neurological examination button prints the findings on a sheet of their own: consciousness, each grid right beside left with only the rows examined, your notes, gait, both maps, seizures and the diagnosis.
One honest limit: neither record charts anything across visits; earlier visits are opened instead.
Neurosurgery: from the outpatient assessment to the operative note
The Neurosurgery department has a record of its own, the Neurosurgical assessment, with the same vital signs and doctor's report as neurology:
- Before the decision. Neurological state holds the same GCS, the Pupils and any focal deficit. Functional status takes the Karnofsky Performance Status (KPS) in steps of 10 and the mRS grade.
- The lesion. Spinal levels involved takes every segment from C1 to S5 a lesion spans, and the side can be Midline for a pituitary lesion. On the Lesion map each mark has a type, a side and a size in millimetres; Imaging context names the CT or MRI, its date and its findings.
- In theatre. Procedure, approach, Intraoperative adjuncts such as neuronavigation, blood loss; the Operating theatre team, anaesthesia and closure; then Operative note details, where Complications asks for “none” rather than an empty box.
- Where the skull was opened. The Craniotomy map shows the skull from above and each side; a mark takes one of twelve approaches, pterional to burr hole, and a size in centimetres.
- What stayed in. The implant and its Implant LOT / batch are typed side by side, so the file says which batch the patient received.
Postoperative course holds the course, the plan and the Next review date. Instructions after the procedure is the take-home sheet: instructions by topic, wound care, activity, warning signs, whom to call. It starts empty on purpose: OPALEVI supplies no stock advice.
The Operative note follows the order of dictation: the linked theatre booking, diagnoses, team, the lesion and craniotomy marks as tables, technique, implant and batch, complications, plan. Nothing is worked out on it. A hospital starts with Operations on, so Book theatre opens the theatre board for this patient; the hospital surgery and ward guide covers the board and the beds.
Referrals, beds and who reads the record
- Between departments. With two or more departments, Refer to a department sends a request that waits on the Referrals worklist until the other side presses Take it on. The emergency department guide shows where many of these start; others come from the orthopaedic clinic with back pain and a weak leg (orthopaedic clinic software), and after a stroke many go on to speech and swallowing therapy (speech therapy software).
- Imaging and files. Radiology keeps its own record (see the radiology software guide); MRI reports, EEGs and nerve-conduction studies attach under Visit documents, up to 10 MB each.
- Beds. A hospital also starts with Patient rooms, for the patient back from theatre. See OPALEVI for hospitals.
Invoice this visit bills the services; invoices are on from registration. At first any colleague with access to clinical records can read these; Record privacy, under Department setup, narrows them to the department or the clinician a record is assigned to. Reception sees no visit history unless allowed, finance never, and Change history logs every edit.
Questions to ask before choosing neurology software
Ask every vendor, OPALEVI included, with one of your own examinations at hand.
| Question | A good answer | OPALEVI |
|---|---|---|
| Is the examination recorded by side? | Right and left columns for nerves, tone, power, reflexes. | Yes: five grids, right beside left. |
| Is the GCS kept as its three responses? | Eye, verbal and motor stored, the total summed. | Yes: the total is calculated. |
| Which other scales are scored? | A clear line between a form and a typed grade. | Partly: mRS and Karnofsky are entered as grades. |
| Do sensory marks carry a dermatome? | A map whose marks name a level. | Yes, with the modality. |
| Are findings charted across visits? | A trend for power or GCS. | No: open the earlier visits. |
| Does it connect to EEG, EMG or scanners? | A tested link, or a clear file route. | No: their reports attach as files. |
| Is the implant batch on the record? | Implant and LOT on screen and on paper. | Yes, printed on the operative note. |
| Does it write post-operative advice? | The surgeon's own words only. | No: the sheet prints what you write. |
The features page lists every module; for billing and what to test in a trial, read how to choose clinic software.
A first week with neurology in OPALEVI
Register
Register as a hospital, or as a clinic or private practice for an outpatient service, and tick neurology and neurosurgery. First steps on the Today screen lists the rest.
Services and paper
Add your services and prices: the starter list already names neurology and neurosurgical consultations, a post-operative check and suture removal. Then Set up the report letterhead.
Rehearse, then invite
Score a GCS and fill the grids on a test patient, print the examination sheet, then Invite your colleagues, each with a role.
Write both sides every time
Fill both columns, even when they match: today's normal right side is what makes next month's weaker left stand out.
Frequently asked questions
What is neurology software?
A program that keeps a neurology service's records in structured form: the GCS, nerves, tone, power and reflexes by side, sensory findings with their dermatome, function grades, seizures, prescriptions and referrals. In a hospital it also carries neurosurgery, from the lesion to the implant and the take-home instructions. It records and prints; the clinical reading stays with the doctor.
Does OPALEVI calculate any neurological score?
One. The Glasgow Coma Scale is entered as its eye, verbal and motor responses, and OPALEVI adds them to a total between 3 and 15. The Rankin grade, the Karnofsky score and the power and reflex grades are entered by the clinician. Nothing is banded, flagged or interpreted.
Can reception see neurology notes?
Not by default. Reception books, admits and takes payment, but reads visit history only if the hospital switches that on; finance staff never can. Among clinicians, Record privacy can keep neurology or neurosurgery records within the department, or with the clinician it is assigned to.
Does it work on a tablet on the ward?
Yes. OPALEVI runs in any current browser on a computer, tablet or phone, with nothing to install. A neurosurgeon can open an assessment at the bedside and read the last GCS before the ward round; on narrow screens the main menu sits at the foot of the page.
Can we try it before paying?
Yes: a free trial, no card, from the day you register. Score a GCS and print an examination sheet on real work. Without a subscription at the end, nothing is billed and your records can still be read.
How is OPALEVI priced for a neurology department?
By seat: one for every staff member holding an active account, with a lower monthly rate when you pay for a year. Patients, departments and devices are never counted. The figures are on the pricing page.
