Documenting a Back and Neck Exam Made Simple | ThriveAP

Whether you’re a seasoned nurse practitioner or a new grad, there’s always room for improvement when it comes to documentation skills. Over the past few months here at ThriveAP, we’ve been looking at documentation basics for the various body systems. Accurately recording the findings of your physical exam is essential for the continued care of your patient and to protect yourself legally as a healthcare provider. What do you need to know when it comes to documenting exam findings of the back and neck?

What You’re Looking For

An exam of the back and neck can indicate a variety of pathologies. Examining the neck, for example, you may find jugular venous distention, a cardiovascular abnormality. Examining the back, you may find costovertebral angle tenderness (CVAT), indicative of a renal abnormality. In this particular blog post, we’ll focus primarily on documentation of musculoskeletal exam findings as these other aspects will be covered in posts for other body systems. 

To adequately assess the back and neck, you must include the following exam components: 

1. Inspection – Assess the back and neck for signs of trauma, post-surgical scars, and signs of pathology such as infection. Look at the alignment of the spine. 
2. Palpation – Palpate the back including the spine and paraspinal region noting areas of tenderness. 
3. Range of Motion – Assess and document range of motion of the neck and back including flexion, extension, rotation, and bend. 
4. Muscle Strength or Tone – Assess strength of the lower and/or upper extremities as necessitated by the patient’s history and presentation. Note and signs of atrophy to the paraspinal muscles. 
5. Sensation – Check sensation of the extremities. 
6. Gait – Observe the patient’s gait and note any abnormalities. An antalgic gait, for example, may be caused by sciatic symptoms. 

Buzzwords to Know

There are a few terms you may encounter in the physical exam of the neck and back that can be helpful to include in your documentation. Familiarize yourself with these terms as you perfect your exam and documentation technique: 

• Antalgic Gait – Occurs when the patient avoids bearing weight on one leg due to pain. The patient bears weight on the affected extremity for the shortest possible amount of time. This can occur with sciatic nerve pain. 
• Saddle Anesthesia – Loss of sensation restricted to the area of the buttocks, perineum, and inner surfaces of the thighs. This is associated with the emergent medical condition, cauda equina syndrome.
• Clonus – Muscle spasm involving repeated, rhythmic contractions. Occurs below an area of spinal cord injury. 
• Costovertebral Angle Tenderness (CVAT) – Pain elicited by percussion over the area of the back overlying the kidney. May indicate renal pathology. 
• Straight Leg Raise (SLR) – Test performed during the physical exam to determine whether the patient with low back pain has a herniated disc.

Sample Normal Exam Documentation 

Documentation of a normal neck and back exam should look something along the lines of the following: 

Neck and back have no deformities, external skin changes, or signs of trauma. Curvature of the cervical, thoracic, and lumbar spine are within normal limits. Bony features of the shoulders and hips are of equal height bilaterally. Posture is upright, gait is smooth, steady, and within normal limits. 

No tenderness is noted on palpation of the spinous processes. Spinous processes are midline. Cervical, thoracic, and lumbar paraspinal muscles are not tender and are without spasm.

No discomfort is noted with flexion, extension, and side-to-side rotation of the cervical spine, full range of motion is noted. Full range of motion including flexion, extension, and side-to-side rotation of the thoracic and lumbar spine are noted and without discomfort.

Straight leg raise test is negative bilaterally. Sensation to the upper and lower extremities is normal bilaterally. No clonus is noted. Grip strength is normal bilaterally. Dorsi/plantar flexion is normal bilaterally. *Note: Strength and reflexes of the lower extremities covered in the extremity and/or neuro exam portion of the note. 

Sample Abnormal Exam Documentation

When documenting an exam abnormality, be as specific as possible about where the abnormality lies. Use words like ‘paraspinal’ and ‘bony’ or ‘vertebral’ to distinguish if tenderness lies over the muscles adjacent to the spine or, over the spinous processes themselves. 

You will likely not document all of these abnormal findings in a single exam, but the following are some neck and back abnormalities you may need to include on your chart: 

• Tenderness (paraspinal or vertebral)
• External abnormalities such as scars, skin lesions, or signs of infection/inflammation
• Signs of trauma such as bruising
• Abnormal curvature of the spine (kyphosis, lordosis)
• Gait abnormalities (ex. antalgic gait, shuffling gait)
• Decreased muscle strength or tone, muscle spasm
• Decreased sensation to the extremities
• Discomfort with or limited range of motion (flexion, extension, rotation)
• Decreased strength in the extremities (ex. limited dorsi/plantar flexion of the feet)
• Clonus
• Positive straight leg raise test
• Abnormal reflexes in the extremities
• Costovertebral angle tenderness

Remember, the back and neck don’t exist in isolation. Abnormal findings on an extremity or neuro exam, for example, may indicate pathology associated with the spine. You should always accompany an exam of the back and neck with an extremity, abdominal, neurological, respiratory, and cardiovascular exam, at least to some extent.