Cognitive-Communication Evaluation Report (Adult)

Patient Name: [Full legal name; include preferred name and pronouns if relevant]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Evaluation Date: [MM/DD/YYYY]

Report Date: [MM/DD/YYYY]

Setting: [acute care / inpatient rehabilitation / outpatient clinic / home health / skilled nursing facility]

Referring Provider: [Name, credentials]

Referral Date: [MM/DD/YYYY]

Reason for Referral: [Brief functional referral question]

Evaluator: [Name, credentials, license # and state]

Documentation Type: [Initial Evaluation / Re-evaluation / Screening Only]

(If any field is unavailable, state "not available" with source of uncertainty.)

Reason for Evaluation

[Referral question prioritizing functional concerns; patient's chief concern in direct quote when available; onset/etiology and timeline; immediate safety or independence concern prompting evaluation] (Use 3–6 sentences. If onset date or key information is unknown, document the uncertainty and source explicitly.)

Case History

Source(s) of Information: [patient / caregiver / chart / interpreter]

Medical/Neurologic History: [Pertinent diagnoses, relevant comorbidities, current symptoms impacting assessment] (Omit unrelated diagnoses; anchor content to cognitive-communication function.)

Medications: [High-level medication issues affecting cognition or participation] (If unavailable, state so.)

Sensory/Motor Considerations: [Hearing and vision status; sensory aids used during assessment; motor impairments affecting testing]

Prior Level of Function (PLOF): [Premorbid cognitive-communication function; work/caregiving/driving/financial responsibilities; education level; literacy]

Current Functional Status: [Living situation; support availability; current independence with medications, scheduling, finances, cooking, device use]

Patient/Care-Partner Goals: [Patient-stated goals; caregiver-stated goals tied to participation outcomes] (If caregiver unavailable, document attempts and plan for collateral.)

Evaluation Methods

Evaluation Conditions: [Positioning; alertness; fatigue/pain level; environmental factors; sensory aids worn; interpreter use if applicable]

Measures Administered:

• Standardized Measures: [Name, version, domains assessed] (Note any deviations from standard administration.)
• Screening Instruments: [Name, domain] (Label explicitly as screening.)
• Patient/Care-Partner Reported Measures: [Name or description]
• Nonstandardized Functional Tasks: [Task descriptions with demands assessed]
• Dynamic Assessment Probes: [Scaffolds/cues tried and response] (Include if applicable.)

Validity Statement: [Behavioral validity indicators: engagement, frustration tolerance, impulsivity, confabulation, perseveration; factors limiting validity: aphasia, motor speech involvement, sensory impairment, fatigue, cultural/linguistic mismatch, modified administration] (If testing procedures were modified, describe modifications and state that norm-referenced scores are not reported due to compromised validity.)

Behavioral Observations

(Document concrete, operationalized observations that contextualize test performance and inform safety planning.)

• Arousal/Orientation: [Level of alertness; orientation to person, place, time, situation]
• Attention/Initiation: [Sustained/selective attention; initiation; latency; distractibility]
• Affect/Pragmatics: [Affect congruence; eye contact; turn-taking; topic management]
• Insight/Awareness: [Indicators of insight; error recognition; risk appraisal]
• Safety Behaviors Observed: [Examples during tasks; adherence to precautions; impulsivity]
• Communication with Unfamiliar Partner: [Overall effectiveness; repair attempts; strategy use]

Assessment Findings

(For each domain assessed, include tasks, objective results with scores/accuracy/cueing level, error patterns, functional implications, and strategies trialed with response. If a domain was not assessed, state why or omit.)

Score Table: (Use when helpful for summarizing standardized results.)

Measure	Domain	Score/Accuracy	Percentile/SS	Interpretation	Notes
[Name/version]	[Domain]	[Value]	[Value or N/A]	[within normal limits / below expected / impaired]	[Cueing, modifications]

Speech/Motor Speech Screen

[Findings relevant to differential diagnosis or impact on testing] (If not indicated, note: Speech was functional and did not impact assessment.)

Auditory Comprehension

• Tasks Assessed: [Following directions of increasing complexity; comprehension of medical instructions; inferencing]
• Objective Results: [Accuracy, latency, cueing level]
• Error Patterns: [Breakdown points; impact of attention/working memory]
• Functional Implications: [Impact on healthcare discussions, safety instructions, daily conversations]
• Strategies Trialed: [Repetition, written supports, chunking; observed benefit]

Verbal Expression and Discourse

• Tasks Assessed: [Confrontation naming; generative naming; narrative/conversational discourse]
• Objective Results: [Accuracy, productivity, informativeness, cueing]
• Error Patterns: [Word retrieval; organization; coherence; tangentiality; repair strategy use]
• Functional Implications: [Impact on communicating needs, phone calls, healthcare advocacy]
• Strategies Trialed: [Semantic/phonemic cueing; multimodal supports; benefit observed]

Pragmatics/Social Communication

(Include when indicated.)

• Tasks/Contexts: [Conversational sample; perspective-taking tasks; implied meaning]
• Findings: [Turn-taking; topic maintenance; perspective-taking; nonliteral language]
• Discrepancies: [Differences between patient and care-partner report]
• Functional Implications: [Impact on relationships, workplace, care coordination]

Reading and Writing

• Tasks Assessed: [Medication labels; appointment information; messaging; forms]
• Objective Results: [Accuracy, speed, cueing level]
• Error Patterns: [Visual-perceptual contributions; spelling; graphomotor issues]
• Functional Implications: [Impact on medication safety, bills, form completion]
• Strategies Trialed: [Text size modifications; highlighting; templates; checklists]

Cognitive-Communication Domains

• Attention and Processing Speed: [Sustained/selective/divided attention; processing speed; objective results; functional impact; strategies trialed and response]
• Memory: [Working memory; new learning; delayed recall; prospective memory; objective results; error patterns; strategies trialed and response]
• Executive Functions: [Planning; organization; inhibition; cognitive flexibility; problem-solving; reasoning; objective results; error patterns; strategies trialed and response]
• Awareness/Metacognition: [Insight; error detection; self-correction; strategy use; impact on safety and independence]
• Visuospatial Skills: [Scanning; spatial organization; visual construction as affecting communication tasks] (Include if relevant.)

Functional Impact and Safety

[Summary of current assistance/supervision needed for cognitively mediated tasks with level, frequency, and context specified]

• Identified Risk Scenarios: [Medication errors / unsafe cooking / inability to follow discharge precautions / financial vulnerability / other]
• Tasks Safe with Caregiver Support: [Tasks with required supervision/cueing boundaries]
• Tasks Requiring Skilled Intervention or Further Evaluation: [Tasks with rationale]

Clinical Impressions

(Integrate findings per ICF framework.)

• Strengths: [Consistent abilities and contexts where observed]
• Primary Limitations: [Ranked by safety and participation impact]
• Activity Limitations: [Everyday tasks impacted]
• Participation Restrictions: [Work, home, community roles affected]
• Contextual Factors: [Facilitators and barriers: caregiver support, insight, motivation, sensory status, mental health, technology access, language/culture]

Diagnosis: [SLP diagnosis, e.g., cognitive-communication disorder secondary to medical condition] (Distinguish from medical diagnosis in chart. If neurocognitive disorder is suspected but not diagnosed, document concern and recommend medical evaluation.)

Severity: [mild / moderate / severe] based on [objective performance and observed assistance needs]

Prognosis

[Prognosis for improvement, compensation, or maintenance; factors supporting or limiting rehabilitation potential: insight, caregiver participation, medical stability, fatigue, comorbidities, response to strategies during evaluation] (Link to observed learning and strategy responsiveness.)

Recommendations

SLP Services: [Recommended / Not recommended]; [setting, frequency, estimated duration, primary focus areas; brief rationale addressing medical necessity] (If not recommended, state rationale.)

Compensatory Strategies:

• [External memory aids with implementation guidance]
• [Environmental modifications]
• [Communication partner strategies]

Caregiver Training: [Cueing techniques; supervision boundaries; safety monitoring; strategy carryover]

Safety Recommendations: [Explicit supervision needs for medications, cooking, finances, community mobility] (If driving or independent living safety is questioned but not assessed, recommend appropriate referral and document scope limitation.)

Referrals: [Neuropsychology / Occupational Therapy / Audiology / Psychology/Psychiatry / Social Work / Driving evaluation / other] (As indicated.)

Plan of Care

(Include when ongoing therapy is recommended.)

Diagnoses Addressed: [List]

Service Plan: [Type, amount, frequency, duration]

Discharge Criteria: [Objective criteria including safety/participation benchmarks]

Long-Term Goals: (1–3 goals tied to safety, independence, or participation.)

• Patient will [functional task] with [accuracy/independence level] given [cueing level] across [consistency criterion] as measured by [data source] within [timeframe].

Short-Term Goals:

• Patient will [component skill or strategy application in functional context] with [accuracy/independence level] given [cueing level] across [consistency criterion] within [timeframe].
• Patient/caregiver will [strategy use or training objective] achieving [criterion] across [number] sessions as measured by [probe or log].

Reassessment Plan: [Baseline measures established; planned reassessment interval and tools]

Patient/Caregiver Education

Topics Covered: [Deficit education; strategy training; supervision guidance]

Response and Understanding: [Patient/caregiver comprehension; teach-back demonstration]

Resources Provided: [Handouts by name and language]

Signature

Clinician Signature: [Name, credentials]

Date: [MM/DD/YYYY]