Cognitive Assessment & Care Plan Note

Date of Service: [date]

Visit Type: Cognitive Assessment & Care Planning

Clinician: [name and credentials]

Participants Present: [patient; caregiver names and relationships; interpreter if used]

Independent Historian: [name; relationship to patient; contact method] (Required for CPT 99483. Document separately from any interpreter used.)

Chief Concern

[Patient and/or caregiver stated reason for visit] (One to two lines. Include direct quotes when clinically valuable. Note triggering event if applicable: AWV positive screen, family concern, safety incident, hospitalization follow-up.)

History Sources & Reliability

Sources: [patient interview / independent historian interview / records reviewed with source and date / other]

Reliability: [Patient reliability statement]. [Independent historian reliability statement]. (Clearly distinguish reliability of each source.)

Cognition-Focused History

[Onset and trajectory of cognitive changes: when first noticed, gradual vs stepwise vs fluctuating course. Cognitive domains affected with specific examples (memory, language, visuospatial, executive function, attention). Neuropsychiatric symptoms including mood, anxiety, apathy, psychosis, agitation, sleep, and appetite changes with duration and severity. Safety concerns such as falls, getting lost, driving incidents, medication errors, fire safety, financial exploitation, or wandering with frequency and most recent occurrence. Patient goals and priorities. Medical contributors under consideration (depression, sleep disorders, medication effects, sensory impairment, substance use).] (Document as narrative paragraphs.)

Functional Assessment

Activities of Daily Living

Basic ADLs: (Rate each as Independent / Needs Assistance / Dependent.)

• Bathing: [Independent / Needs Assistance / Dependent]
• Dressing: [Independent / Needs Assistance / Dependent]
• Toileting: [Independent / Needs Assistance / Dependent]
• Transferring: [Independent / Needs Assistance / Dependent]
• Continence: [Independent / Needs Assistance / Dependent]
• Feeding: [Independent / Needs Assistance / Dependent]

Instrumental ADLs:

• Telephone/Technology: [Independent / Needs Assistance / Dependent]
• Shopping: [Independent / Needs Assistance / Dependent]
• Food Preparation: [Independent / Needs Assistance / Dependent]
• Housekeeping: [Independent / Needs Assistance / Dependent]
• Laundry: [Independent / Needs Assistance / Dependent]
• Transportation: [Independent / Needs Assistance / Dependent]
• Medication Management: [Independent / Needs Assistance / Dependent]
• Finances: [Independent / Needs Assistance / Dependent]

Current Assistance: [Who assists with which tasks; living arrangement and supervision level]

Decision-Making Capacity

Healthcare decision capacity: [Able / Not able / Uncertain]

Financial decision capacity: [Able / Not able / Uncertain]

(If uncertain, specify further evaluation needed and interim safeguards.)

Surrogate decision-maker: [name; relationship; contact] (Include if applicable.)

Standardized Assessments

(For each instrument: document name/version, date administered, administrator, score with interpretation, and validity limitations. Note where raw scoring forms are stored.)

Cognitive Screening: [instrument and version], administered [date] by [clinician / staff / caregiver]. Score: [score], interpretation: [impairment level]. Limitations: [language / education / hearing / vision / aphasia / none]. Raw forms: [location].

Dementia Severity/Staging: [instrument and version], administered [date] by [role]. Stage: [stage designation]. Limitations: [limitations]. Raw forms: [location].

Neuropsychiatric Symptoms: [instrument and version], administered [date] by [role]. Score: [score], interpretation: [symptom profile]. Limitations: [limitations]. Raw forms: [location].

Caregiver Burden: [instrument and version], administered [date] by [role]. Score: [score], interpretation: [burden level]. Raw forms: [location]. (Include when caregiver strain is a concern; otherwise omit.)

Safety Evaluation

Home Environment: [supervision level; hazards identified; fall risks; emergency plan] (Enter findings or "not applicable.")

Medication Safety: [self-administration ability; adherence issues; pillbox or compliance aids; controlled substance concerns]

Driving: [current driving status; concerns or incidents; plan: counseling / formal evaluation / cessation / alternative transportation]

Wandering Risk: [prior episodes; prevention measures in place (door alarms, ID bracelet, tracking)]

Financial Vulnerability: [exploitation concerns; scam susceptibility; POA status]

Abuse/Neglect Screening: [screening result] (Document mandated reporting actions if triggered.)

Medical History & Medications

Pertinent medical history: [vascular risk factors; stroke/TIA; head trauma; parkinsonism; psychiatric history; substance use; family history of dementia]

Social history relevant to cognition: [education; primary language; occupation; current living arrangement and supports]

Medication Reconciliation

Confirmed medication list: [medications with doses and frequencies] — Verification source: [patient / caregiver / pharmacy / EMR / other]

High-risk medication review: [anticholinergics; sedatives; opioids; polypharmacy concerns; actions taken or monitoring plan]

Current medication management: [who sets up medications; tools used (pillbox, blister packs); adherence pattern]

Examination & Data Reviewed

Vitals: [BP; HR; RR; Temp; SpO2; Weight/BMI] (Include orthostatic measurements if falls or syncope are concerns.)

Neurological exam: [gait; tremor; focal deficits; tone; coordination]

Sensory status: [hearing; vision] (Note implications for cognitive test validity.)

Labs reviewed: [test; date; key findings] (Include only if reviewed today.)

Imaging reviewed: [study; date; key findings] (Include only if reviewed today.)

Other data reviewed: [neuropsych testing; consult notes; dates] (Include only if reviewed today.)

Assessment

Working Diagnosis: [specific diagnosis with qualifier, e.g., "Major neurocognitive disorder due to probable Alzheimer disease"]

Severity/Stage: [stage tied to staging instrument results and functional status]

Supporting Evidence: [key history findings; standardized assessment results; functional decline; exam findings; diagnostic data]

Differential Considerations: [alternative or contributing etiologies]

Clinical Reasoning: [brief synthesis explaining diagnostic conclusions and complexity factors]

Care Plan

(Document actionable items by domain. For each action, specify responsible party and timeline. Use clear, shareable language.)

Cognitive Symptoms

• [Diagnostic workup: labs, imaging, neuropsych referral] — Responsible: [party]; Timeline: [timeframe]
• [Cognitive health interventions: sleep, exercise, hearing optimization] — Responsible: [party]; Timeline: [timeframe]
• [Medication plan with rationale and monitoring] — Responsible: [party]; Timeline: [timeframe]

Neuropsychiatric Symptoms

• [Non-pharmacologic strategies] — Responsible: [party]; Timeline: [timeframe]
• [Medication plan if applicable with monitoring requirements] — Responsible: [party]; Timeline: [timeframe]

Functional Support

• [Therapy referrals: OT / PT / ST] — Responsible: [party]; Timeline: [timeframe]
• [Home safety evaluation; DME needs] — Responsible: [party]; Timeline: [timeframe]
• [ADL/IADL assistance plan; supervision needs] — Responsible: [party]; Timeline: [timeframe]

Safety Interventions

• [Driving plan: counseling / formal evaluation / cessation / alternative transportation] — Responsible: [party]; Timeline: [timeframe]
• [Medication supervision plan] — Responsible: [party]; Timeline: [timeframe]
• [Wandering prevention: alarms / ID / tracking] — Responsible: [party]; Timeline: [timeframe]
• [Fall prevention measures] — Responsible: [party]; Timeline: [timeframe]
• [Financial protection: POA, safeguards] — Responsible: [party]; Timeline: [timeframe]

Caregiver Support

• [Education provided: topics and format] — Recipient: [caregiver name]
• [Respite options; support group referral] — Responsible: [party]; Timeline: [timeframe]
• [Caregiver health needs identified and plan] — Responsible: [party]; Timeline: [timeframe]

Referrals & Resources

• [Referral: neurology / geriatrics / psychiatry / social work / neuropsychology / community agency / adult day program] — Rationale: [reason]; Timeline: [timeframe]

Follow-Up

Next appointment: [timeframe or date]

Triggers for earlier contact: [specific symptoms or safety issues]

Safety check-in plan: [modality and timing] (Include if active safety risks identified.)

Advance Care Planning

Status: [Reviewed / Updated / Newly created / Declined] (If declined, document plan to revisit.)

Documents on file: [Healthcare proxy/DPoA; living will; POLST/MOLST] — Location: [where stored]

Current decision-maker: [name; relationship; contact] (Include if patient lacks capacity.)

Goals-of-care summary: [key points and preferences discussed] (Include only if discussion conducted.)

Care Coordination

Care plan shared with: [patient / caregiver / both] — Method: [printed / portal / AVS / secure message]

Referrals placed: [list with status: ordered / scheduled / completed]

Communication with other clinicians: [who; method; summary] (Note consent for external sharing if applicable.)

Time & Service Documentation

Total clinician time on date of service: [minutes]

Independent historian attestation: [Independent historian present and utilized / patient declined / unavailable — reason and plan if not completed]

(All required service elements for cognitive assessment and care planning were addressed. If any required elements were not completed, document reason and plan to complete; consider alternative billing if elements cannot be obtained.)