NAME:XXX, XXXXPATIENT #:
EXAM DATE:EDUCATION:X years
[One or two sentences describing reason for referral. Should include symptoms/diagnosis warranting neuropsychological consult]
[OPTIONAL SECTION – RESULTS SUMMARY: [one or two sentences summarizing findings of neuropsychological evaluation. For example: Neuropsychological evaluation was abnormal with deficits in memory and language. (if surgical patient: Patient is a (fill in appropriate descriptor – poor/fair/good surgical candidate) (if dementia patient: Data consistent with (fill in likely etiology)]
CURRENT COMPLAINTS AND HISTORY
[Specify where data was obtained, e.g., patient and spouse]
[Brief summary of presenting complaints, if any. The history of complaints, when the symptoms started, severity, and course should be specified].
Example – bullet format:
Seizures/Epilepsy. Patient has a history of seizures since childhood. Seizures medication refractory. Seizures occur 2/month on average. Last known seizure was _____.
Attention, memory, and language problems past 2 years. Increasing problems concentrating the past 2 years. Forgets details of recent events, appointments, and repeats self. Increasing dysnomia the past 2 years. Speech problems past ____.
Depression for past year. Symptoms of depression more often than not the past year. Denied anxiety symptoms. Sleep and appetite were _____. Difficulty falling asleep and his/her appetite has decreased with loss of 15 pounals past 6 months without dealing. Energy level was _____.
MEDICAL AND PSYCHIATRIC HISTORY: [Relevant medical and psychiatric history specified. This may only be noted as “unremarkable” or “noncontributory” but may also include information about neurological exam, laboratory studies, EEG, MRI, CT, surgical/operative notes, consulting notes of other health care providers, previous diagnosis(es) and treatments (successful or unsuccessful). Allergies may also be stated.).
[Review of developmental, social, educational, occupational history provided. One may also make a statement about patient’s ability to complete activities of daily living (ADLs). Can be brief, for example “Patients medical and psychiatric history was reviewed and detailed in chart. Otherwise unremarkable. Developmental history unremarkable. Patient worked as an engineer and retired in 2003. Patient is independent in ADLs and is driving.]
CURRENT MEDICATIONS: [list medications and dosages]
MENTAL STATUS AND GENERAL CONSTITUTION
[Detail the patient’s mental status. At a minimum, the patient’s level of arousal and orientation should be noted along with observations about gait and station, stature, and hygiene. Quality of speech should be reviewed along with mood and affect. Presence/absence of suicidal and/or homicidal ideation, intent or plan along with hallucinations or delusions should be specified. The patient’s cooperation with the evaluation should be noted.]
[A comment about task engagement or validity of the study may be made here or in the neuropsychological results section. An example is given below.]
Appearance: well groomed. Appeared stated age. Of normal height and build.
Tremor: No obvious tremor observed.
Speech: articulation and rate, rhythm, intonation, and prosody WNL.
Speech Content: generally appropriate to context.
Speech Process: organized and goal-directed.
Affect: consistent with mood
Suicidal/Homicidal Ideation Plan or Intent: denied
Judgment: within normal limits
Insight: within normal limits
Test Taking Behavior: Cooperative and appeared to give adequate effort. Study is valid.
[Specified the assessment procedures including what tests were administered. We advise the clinician to specify inclusion of symptom validity measures as such, and not identify specific test names.]
SENSORY/MOTOR AND PERCEPTUAL FUNCTIONING
[Results from sensorimotor and perceptual testing, if completed, specified here. This may also include results from neurological exam, if completed. Presence of finger agnosia, visual field defects, etc. and motor exam (motor speed, dexterity, and/or grip strength.] Example is below.
Sense of smell: intact to several common scents.
EOM: appeared grossly intact.
Visual fields: grossly full to confrontation.
Light touch: Sensation intact in face and hands, and no extinction with bilateral simultaneous stimulation.
Auditory: intact, bilaterally
Ideomotor apraxia: None (or Yes, present)
Agraphasthesia: None (or Yes, present)
Finger agnosia: None (or Yes, present)
R/L orientation: Intact (or Impaired)
Grip strength: [description of performance. Example “Average, bilaterally.”]
Finger tapping speed: [description of performance]
Manual dexterity: [description of performance]
NEUROPSYCHOLOGICAL FUNCTIONING [OR RESULTS]
[Provide results of test scores here. May be separated into major domains or a summary of performances provided]. See examples below. We recommend the inclusion of a summary table of neuropsychological scores (including standardized scores) be included in most neuropsychological reports either imbedded or as an appendix. Base rate information regarding the frequency in which score differences are observed in healthy samples and/or if results exceed reliable change scores (if known) may be included. No references needed. [Note: the reporting base rate and/or discrepancy information provided following recommendations for evidenced-based neuropsychology practice (Chelune 2010)].
Premorbid functioning estimated to be high average to superior. General cognitive functioning was average. The patient exhibited deficits in areas of attention/executive functions, verbal memory, and language functions. Specifically, the patient exhibited mild to moderate deficits in complex focused and divided attention tasks. Verbal immediate and delayed memory scores were mildly impaired. Language screening was grossly functional, but there were deficits in confrontation naming and verbal fluency. Strengths were basic span of attention, receptive and expressive language functions, and visuoperceptual skills.
Premorbid functioning: Estimated to be high average to superior in general cognitive ability.
General Cognitive: High average compared to age-matched peers. Indices of verbal and nonverbal abilities were high average and average, respectively (Verbal Comp.= 115, 84th %; Perceptual Reasoning=100, 50th %).
Processing Speed: WNL.
Attention: Intact for basic functions. Impaired for complex attention
Memory: Impaired verbal memory. Intact visual memory. Differences in scores infrequent in healthy sample.
Language: Impaired confrontation naming and verbal fluency. Unable to follow 3-step instructions. Otherwise receptive and expressive speech grossly intact. Repetition intact. No alexia or agraphia.
Visuoperceptual/visuoconstructional: Grossly intact. No constructional apraxia
Executive functions (insight, judgment, reasoning): impaired. Insight and judgment [intact, impaired, etc.]
Brief Results Section Example
The patient exhibited deficits in areas of attention/executive functions, verbal memory, and language functions. Specifically, the patient exhibited mild to moderate deficits in complex focused and divided attention tasks. Verbal immediate and delayed memory scores were borderline to impaired compared to age-matched peers. Language screening was functional, but the patient exhibited deficits in confrontation naming (BNT = 38/60) and phonemic and semantic verbal fluency scores.
Strengths were in basic attention functions, general cognitive (intellectual) functioning was average, and visuoperceptual and visuoconstructional skills were entirely intact.
PSYCHOLOGICAL AND PERSONALITY FUNCTIONING
[Provide results of any psychological or personality testing done. See example below]
The patient completed the BDI-2 and STAI. He reported mild to moderate symptoms of depression and anxiety. The patient denied rumination and appeared well adjusted.
CONCLUSIONS AND DIAGNOSTIC IMPRESSIONS
[Interpretation of neuropsychological results. Statement(s) to answer the referral question(s) should be clearly specified. Diagnoses should be listed. If combined with recommendations, recommendations should flow from interpretation.] See example below.
Neuropsychological study was [abnormal, equivocal, normal]. [If abnormal, describe what was abnormal].
For example: The study was abnormal due to deficits in attention/executive functions, verbal memory, and language functions. There were mild to moderate symptoms of depression. Strengths included the patient’s basic span of attention, nonverbal “visual” memory, visuoperceptual and visuoconstructional skills.
[If relation to neuroanatomical function is needed, specify here. For example: Assuming normal neuroanatomical functional organization, data suggest left frontotemporal dysfunction, and consistent with history of left temporal mesial temporal scelrosis.] [In dementia example. Neuropsychological data are generally consistent with a dementia of the Alzheimer’s type. A less likely possibility is a frontotemporal dementia (FTD) process. History of symptoms argues against FTD].
[If surgical candidacy is a referral question, clearly specify neuropsychological opinion. For example: Surgical candidacy: From a neuropsychological standpoint, the patient is a (poor, fair, good, excellent) candidate for (left, right, extratemporal, multilobar, corpus callosotomy, DBS, VNS, CABG, renal/hepatic transplantation, spinal fusion, morphine pump, etc.]. The patient is at (low, medium, high) risk for post-surgical (language, memory, attention/executive, psychiatric, etc.) problems. The patient is likely a good candidate for [additional diagnostic/laboratory procedures to further evaluate for potential risks to the patient.].
[If feedback notation is included in same report. For example: Initial results of the neuropsychological evaluation were reviewed with the patient, and all questions were answered to his/her/their satisfaction. As much detail as is necessary is appropriate here.].
Diagnostic Impressions: [List diagnostic conditions here. Should follow ICD-9 or DSM-IV diagnostic codes].
[List recommendations for the patient’s care here.] These will vary widely depending upon the individual patient. However, some common domains for recommendations are provided below:
Referral for further work-up of condition.
Recommend consultation by another specialist/subspecialist
Initiate treatment for psychiatric/psychological symptoms
Initiate treatment/rehabilitation for cognitive deficits
Cognitive ability to make medical, legal, and/or financial decisions (capacity is a legal term and decided by a court – not a neuropsychologist).
Cognitive and/or behavioral prognosis based on available data
Summary of deficits with prognosis for recovery
Participate in medical treatment
Escort to and from all activities
Shortened therapy sessions
Memory notebook training
Problem solving training
Occupational recommendations/driving restrictions
Capacity to return to work (school if child)
Schedule to return if unable to return to full time work
Accommodations necessary for successful re-integration
Reference of local, state, regional, national, or international support and advocacy groups of any known disorders/conditions.
Specify diagnosis for Americans with Disabilities Act (ADA) and/or Individuals with Disabilities Education Act (IDEA 2004).
Specify need for IEP (based on diagnosis/diagnoses)
Specify what accommodations and/or adaptations may be helpful to the patient academically, socially, emotionally, and/or vocationally.
[If appropriate, make statement(s) about return to work/school. If not return to work/school now, when, and if accommodations (as above) are likely to be needed.].
[Specify if follow-up is needed].
[Closure of report and include information, if appropriate, for further contact and information if desired. Include information about services provided [Services included: Neuropsychological evaluation (_____ hours including administering, scoring, interpretation and report writing). Psychometrician-based neuropsychological assessment (____ hours).]