Neuropsychological Screening Note (Rehabilitation)

Date/Time: [Date and time of screening]

Setting: [IRF / acute care / SNF / outpatient / telehealth]

Evaluator: [Name, credentials, discipline]

Contact Type: [bedside / clinic / telehealth] [Interpreter used: yes/no] [Language if interpreter used]

Time Spent: [Total face-to-face time]

Reason for Consult: [One-line problem statement driving the screening]

Referral Question & Rehabilitation Context

[Who requested screen and why] [Patient's rehabilitation phase and primary rehab goals] [Decisions this screen is intended to inform] (2–4 sentences; use screening-level language such as "consistent with," "suggestive of," or "screen indicates.")

Sources of Information & Assessment Conditions

• Sources: [Patient interview, chart review, collateral contacts] (Note reliability of each source.)
• Factors affecting validity: [Language/interpreter; arousal/fatigue/pain/medication effects; motor/speech limitations; delirium precautions; telehealth constraints; nonstandard administration] (Include only factors present; note impact on interpretation.)

Relevant History

• Primary diagnosis: [Neurologic event/diagnosis and date]
• Current medical issues: [Issues relevant to cognition: infection, metabolic, sleep, pain]
• Psychiatric history: [History relevant to rehab participation]
• Premorbid baseline: [Education, occupation, living situation, supports]
• Current functional status: [ADLs/IADLs, mobility, therapy participation]
• Relevant medications: [Sedatives, anticholinergics, stimulants, recent changes]

(If history unavailable or unreliable, state so explicitly with reason.)

Behavioral Observations

• Cooperation/engagement: [Participation, rapport, persistence]
• Speech/language: [Fluency, comprehension, word-finding, response latency]
• Affect/mood: [Observed range, congruence, emotional regulation]
• Orientation: [Person, place, time, situation]
• Attention: [Sustained focus, distractibility, need for redirection]
• Insight: [Awareness of deficits and their impact]
• Effort/consistency: [Response consistency throughout session] (Use neutral behavioral descriptors.)
• Safety/behavioral concerns: [Risk screen summary and actions taken] (Include only if present.)

Measures Administered

• [Standardized instruments: name and version] (Do not reproduce test items.)
• [Nonstandard/functional tasks] (Clearly label as nonstandard.)

(If no standardized measures administered, state: "Clinical interview and behavioral observation only; no standardized measures administered due to [reason].")

Results

(Report only domains assessed. For core domains not assessed, state "Not assessed.")

• Attention/Processing Speed: [within expected limits / mildly reduced / moderately reduced / severely reduced / not assessed] [Brief supporting observations]
• Orientation/Working Memory: [within expected limits / mildly reduced / moderately reduced / severely reduced / not assessed] [Brief supporting observations]
• Learning & Memory: [within expected limits / mildly reduced / moderately reduced / severely reduced / not assessed] [Note encoding vs retrieval, cueing benefit]
• Executive Functions: [within expected limits / mildly reduced / moderately reduced / severely reduced / not assessed] [Note initiation, planning, flexibility, inhibition]
• Language/Communication: [within expected limits / mildly reduced / moderately reduced / severely reduced / not assessed] [Note comprehension, naming, fluency]
• Visuospatial/Neglect: [within expected limits / mildly reduced / moderately reduced / severely reduced / not assessed] [Note construction, neglect if relevant]
• Social Cognition/Behavior Regulation: [within expected limits / mildly reduced / moderately reduced / severely reduced / not assessed] (Include if relevant.)
• Mood/Anxiety Screening: [within expected limits / elevated symptoms / not assessed] [Brief indicators]

Validity/Reliability: [Results consistent with observed behavior / Interpretation limited due to specific factors] (State contributing factors if limited: fatigue, aphasia, pain, delirium, inconsistent effort.)

Summary

[One-sentence global summary of cognitive/behavioral profile] [Identified strengths and weaknesses] [Most likely contributors: neurologic injury plus modifiable factors] [Confidence level given any limitations] (3–6 sentences; frame as screening-level impressions, not diagnostic conclusions.)

Functional Implications for Rehabilitation

• Learning/carryover: [Ability to retain strategies across sessions; generalization expectations]
• Cueing needs: [Type and frequency; errorless learning, spaced retrieval, external prompts if indicated]
• Communication supports: [Simplified language / one-step commands / extra response time / written choices / visual aids]
• Safety/judgment: [Impulsivity, insight, neglect, wandering risk; supervision and redirection needs]
• Endurance/behavioral tolerance: [Fatigue patterns, irritability triggers, optimal session length and scheduling]
• Supervision level: [Recommendations during therapies, ADLs, mobility]

Recommendations

Team Recommendations

• [Communication strategies for staff]
• [Environmental modifications]
• [Memory and executive supports: whiteboard, checklists, therapy notebook] (Indicate responsible discipline.)
• [Behavior management strategies if needed] (Assign staff roles.)
• [Criteria for re-screening or full neuropsychological evaluation]
• [Referrals: SLP, psychiatry, OT driving evaluation, other]

Patient/Family Recommendations

• [Plain-language explanation of findings]
• [Practical strategies family can reinforce]
• [Expectations for recovery and follow-up]
• [Safety recommendations for home if relevant]

(If patient/family not engaged, document reason and plan for later education.)

Plan

[Follow-up timing and triggers for re-screening] [Whether full neuropsychological evaluation recommended and rationale] [Outpatient follow-up if applicable] [Team members updated and communication method]