Neurocognitive Screening Note (MoCA/MMSE)

Date/Time: [date and time of encounter]

Location: [clinic / facility / telehealth]

Visit Type: [screening-only / part of AWV / routine visit / follow-up]

Clinician: [clinician of record]

Test Administrator: [name and role if different from clinician] (Omit if same as clinician.)

Patient Language: [primary language; interpreter used: yes / no]

Sensory Aids: [hearing aids / glasses / none] (Omit if not applicable.)

Reason for Screening

[Brief narrative of the trigger for today's screening, primary symptom domain if symptom-triggered, time course and trajectory, and patient goals for the encounter] (Write 2–4 sentences. If routine screening without specific concerns, state this clearly. If follow-up of prior screening, reference purpose and interval.)

Relevant History

Informant/Collateral: [informant name, relationship, and reliability; summary of key observations relevant to cognition and daily function] (If collateral was not obtained, document "No collateral available today.")

Functional Status:

• [Instrumental activities: medications, finances, driving, shopping, meal preparation, appointments—describe current status and any recent changes with concrete examples; note who assists if applicable]
• [Basic ADLs: bathing, dressing, toileting, feeding] (Include only if concerns were reported or observed.)

Relevant Medical Context:

• [Neurologic history: prior stroke/TIA, Parkinsonism, seizures, TBI, OSA, recent hospitalization or acute illness] (Include only items pertinent to this patient.)
• [Psychiatric and sleep factors: depression/anxiety symptoms, recent stressors, insomnia or sleep deprivation] (Note if formal mood screening was completed.)
• [Substance use: alcohol, sedatives, other substances relevant to cognition] (Omit if not applicable.)

Medications: [potentially cognitively impairing medications such as anticholinergics, sedatives, or opioids; note any recent changes relevant to cognitive concerns] (Omit if none identified.)

(If any critical confounder that could affect interpretation could not be assessed—e.g., medication list unavailable—document explicitly here.)

Testing Conditions

• Environment: [quiet room / busy environment / telehealth]
• Sensory/Motor Factors: [hearing and vision adequacy; motor issues affecting drawing or writing such as tremor or weakness]
• Language/Education: [test administered in patient's primary language: yes / no; years of education if relevant to score interpretation; literacy concerns if present]
• Patient State: [alertness, fatigue, pain, acute illness, attention level; any concern for delirium]
• Validity/Effort: [clinician judgment of engagement and effort; note any sections refused or not attempted and why]

(If any assistance or cues were provided during testing, document explicitly.)

Screening Results

• Instrument: [MoCA / MMSE; version or form; language version; paper / digital]
• Prior Testing: [prior date and score] (Omit if no prior testing.)
• Score: [total] / [maximum]
• Education Adjustment: [adjustment applied and resulting score] or [not applied; rationale]
• Domain Summary: [brief note of relative weaknesses by domain without reproducing test items] (Optional; omit if unremarkable.)

Interpretation: [contextual interpretive statement that frames the result as a screening finding, accounts for testing conditions and confounders, and states whether findings suggest need for further evaluation or are reassuring] (Use neutral screening language; avoid diagnostic labels.)

(If testing was not completed, document "Test not completed" with reason and proposed plan for repeat or alternate assessment.)

Objective Observations

(Include this section when the screen is abnormal, safety concerns are present, or a referral is planned; omit for routine normal screening without concerns.)

• [General appearance and behavior]
• [Alertness and attention]
• [Speech and language impression]
• [Affect and observed mood]
• [Focused neurologic observations relevant to cognition: gait, tremor, focal deficits] (Include only if assessed.)

Assessment

Screening Conclusion: [normal / abnormal / borderline / uninterpretable] — [brief reasoning tied to the score, testing conditions, and any confounders such as language, education, sensory impairment, mood symptoms, or acute illness] (Clearly state that this is a screening interpretation, not a diagnosis.)

Functional Correlation: [link cognitive screening findings to functional observations when concerns are present; if borderline or abnormal with intact function, note potential educational or language factors and need for confirmatory evaluation]

Differential Considerations: [brief prioritized list of possibilities based on clinical picture—e.g., neurodegenerative processes, vascular contributions, mood or sleep effects, medication or substance effects, delirium if acute features present] (Emphasize uncertainty and avoid definitive diagnoses based on screening alone. Omit if screen normal and no concerns.)

Plan

Diagnostic Next Steps:

• [Collateral history: from whom, expected date and method] (Omit if already obtained.)
• [Laboratory evaluation for reversible contributors: specify tests] (Omit if not indicated.)
• [Imaging or advanced evaluation if appropriate]
• [Referrals: neurology / geriatrics / neuropsychology; specify purpose]
• [Repeat screening: timing, instrument or form, conditions to optimize]

Modifiable Factors: (Omit if none identified.)

• [Medication review or deprescribing plan for cognitively impairing agents]
• [Vascular risk factor management steps]
• [Sleep optimization or OSA evaluation and treatment]
• [Mood assessment or treatment plan]
• [Hearing or vision correction steps]

Safety: (Include when any concern exists; omit if no safety concerns.)

• [Driving: counseling provided, whether formal driving evaluation is recommended; if uncertain about fitness, recommend evaluation rather than declaring unfit]
• [Home safety: falls, stove use, wandering risk; mitigation steps]
• [Firearms access counseling]
• [Medication supervision or assistance plan]
• [Financial vulnerability safeguards]

Counseling: [document that the meaning and limitations of screening were explained; that screening does not establish a diagnosis; rationale for next steps; patient and caregiver understanding]

Follow-up: [specific interval and purpose—e.g., return for workup results in X weeks, or rescreen in Y months if stable; include return precautions for acute confusion, rapid decline, or safety events]

Results Communication: [with whom results were shared: patient, caregiver with consent, PCP; method of communication] (Include for abnormal results only; omit for routine normal screens.)

(Do not reproduce test items or full instrument content; document scores and clinical interpretation only. Frame all interpretive language around screening, not diagnosis. Omit sections that do not apply. Capacity determinations require separate, specific documentation and should not be inferred from screening scores. If billing under CPT 99483, ensure additional required elements are documented: decision-making capacity assessment, medication reconciliation, standardized neuropsychiatric assessment, caregiver needs identification, advance care planning discussion, and written care plan.)