Pre-Surgical Neuropsychological Evaluation Report

Report Header

Document Title: Pre-Surgical Neuropsychological Evaluation Report

Patient Information: [Full name]; [MRN]; [Date of birth]; [Age]; [Handedness]; [Preferred language]; [Gender identity] (Include only if clinically relevant)

Referral Information: [Referring clinician/service]; [Receiving surgical program: Epilepsy Surgery Conference / DBS Team / Tumor Board / other]; [Date(s) of evaluation]; [Date of report]

Evaluator: [Name, credentials, licensure]; [Institution]; [Contact information]

Encounter Details: [Evaluation setting: in-person / telehealth]; [Interpreter use: none / yes with interpreter name/ID]; [Testing environment notes] (Include environment notes only if relevant)

Confidentiality: This report is intended for clinical use by the referring treatment team. Test materials and raw stimuli are protected and not to be distributed.

Reason for Referral

Proposed Procedure(s): [Procedure under consideration: epilepsy surgery / DBS / tumor resection / other] (If procedure not finalized, list options under consideration and note that risk discussion will be structured by scenario.)

Clinical Questions:

• [Clinical question 1: baseline cognitive profile and functional implications]
• [Clinical question 2: procedure-specific cognitive risks, domain-specific and lateralized when relevant]
• [Clinical question 3: neurobehavioral or psychiatric risk factors affecting perioperative outcomes]
• [Clinical question 4: decision-making capacity for informed consent or postoperative self-management] (Include only if requested or indicated)
• [Clinical question 5: recommendations to mitigate risk and support perioperative care]

Sources of Information

(List all records and informants reviewed. Explicitly note if key records were requested but unavailable. If no external records were available, state this rather than omitting.)

• [Neurology and neurosurgery notes with approximate dates]
• [Imaging reports with dates]
• [EEG/EMU summaries; Wada or fMRI mapping results if applicable]
• [Prior neuropsychological reports]
• [Medication list source]
• [Collateral informants: name, relationship, participation method]
• [Patient-provided materials]
• [Records requested but not obtained] (Include only if applicable)

Procedures and Method

Consent: [Informed consent documentation, including discussion of confidentiality limits and intended recipients] (If capacity to consent to evaluation was questionable, note surrogate involvement.)

Tests Administered by Domain:

• Attention/Working Memory: [Tests administered]
• Processing Speed: [Tests administered]
• Language: [Tests administered]
• Visuospatial/Constructional: [Tests administered]
• Learning and Memory: [Tests administered, verbal and visual]
• Executive Functions: [Tests administered]
• Motor Skills: [Tests administered] (Include only if assessed)
• Performance Validity Measures: [Measures administered]
• Behavioral Health Screening: [Instruments used] (Include only if administered)

Normative Framework: [Norms used and any cultural or linguistic considerations affecting test selection or interpretation]

Service Components: [Interview time]; [Testing time]; [Scoring time]; [Interpretation time]; [Feedback time if provided]; [Date(s) of service]; [Personnel performing each component] (Include for billing documentation when required)

Pertinent History

(Label information source throughout as patient-reported, record-confirmed, or collateral-reported.)

Presenting Concerns

[Patient's primary cognitive concerns with functional examples from work, school, or daily life; brief direct quote if clarifying goals or risk perception]

Surgical Indication and Neurodiagnostic Summary

(Tailor content to referral type.)

• For Epilepsy: [Seizure types and frequency]; [Age of onset]; [Lateralization and localization hypotheses]; [EMU/EEG highlights]; [Prior Wada or fMRI mapping results]
• For DBS: [Primary symptoms]; [Motor fluctuations]; [Medication response]; [Relevant neuropsychiatric history]; [Target under consideration]
• For Tumor/Structural Lesion: [Tumor type if known]; [Location and hemisphere]; [Edema or mass effect]; [Treatments to date]; [Planned surgical approach if known]

Medical and Psychiatric History

• Neurologic: [Stroke, TBI, CNS infections, developmental disorders, sleep disorders, sensory deficits]
• Medical: [Conditions with cognitive implications]
• Psychiatric/Behavioral: [Diagnoses, treatment status, stability; history of suicidality or hospitalization when relevant to surgical candidacy]

Developmental, Educational, and Occupational Background

[Developmental history]; [Highest education, learning disability or special education history, language of instruction]; [Occupational complexity and current work status]; [Baseline functioning and decline trajectory for older adults]

Medications and Substances

[Current medications with cognitive or behavioral relevance: anti-seizure medications, sedating agents, anticholinergics, dopaminergic agents, opioids, benzodiazepines]; [Medication timing relative to testing]; [Alcohol, cannabis, or other substance use relevant to testing or perioperative risk] (If medication list unavailable, explicitly state this.)

Behavioral Observations

[Appearance and behavior]; [Cooperation and rapport]; [Fatigue or pain]; [Motor or sensory limitations]; [Speech and language characteristics]; [Mood and affect]; [Thought process]; [Orientation]; [Effort and engagement] (Use neutral, non-accusatory language); [Observations relevant to insight, judgment, or capacity for self-management]

Test Results

Validity Statement

[Overall validity conclusion based on performance validity measures and behavioral consistency; if validity is limited, specify which domains are affected and what conclusions remain supportable] (This statement is required when formal testing is interpreted.)

Cognitive Findings by Domain

(Present only assessed domains. Provide brief interpretive summary with functional translation. Detailed score tables belong in appendix.)

• Estimated Premorbid Functioning: [Interpretive summary and functional implications]
• Attention and Working Memory: [Interpretive summary and functional implications]
• Processing Speed: [Interpretive summary and functional implications]
• Language: [Interpretive summary and functional implications]
• Visuospatial and Constructional Skills: [Interpretive summary and functional implications]
• Learning and Memory: [Interpretive summary and functional implications, verbal and visual]
• Executive Functions: [Interpretive summary and functional implications]
• Motor Skills: [Interpretive summary and functional implications] (Include only if assessed)

Emotional and Behavioral Findings

[Summary of depression, anxiety, apathy, irritability, or other mood and behavioral findings from screening measures and interview; psychosis risk indicators if present; somatic symptom burden relevant to surgical candidacy] (Interpret personality measures conservatively with attention to clinical management implications.)

Functional Status

[Everyday functioning including ADLs/IADLs, medication management, financial management, driving and work safety considerations] (Clearly label collateral-reported information. Include only if assessed.)

Integrated Summary

[Cohesive synthesis of referral context and clinical questions; key cognitive strengths and weaknesses; major modifying factors including mood, sleep, medications, pain, and effort; functional implications; diagnostic impressions phrased as impressions rather than certainties when data are incomplete] (Focus on clinical integration; avoid restating detailed findings.)

Pre-Surgical Risk Assessment

(Translate baseline findings into procedure-specific risk estimates. If specific procedure is unknown, structure discussion around likely scenarios based on referral context.)

Procedure Scenario: [Procedure name and lateralization if applicable]

(Repeat this subsection for each procedure scenario under consideration.)

• Anticipated Cognitive Risks: [Domain-specific risks with lateralization considerations; e.g., language and memory for dominant temporal procedures; executive, processing speed, and mood/behavior for DBS; attention, executive, and fatigue for tumor contexts]
• Risk Modifiers: [Age]; [Baseline impairment level]; [Mood status]; [Sleep]; [Seizure burden or motor fluctuations]; [Anticipated medication changes]; [Functional reserve]
• Counseling Points: [Realistic expectations]; [Potential trade-offs]; [Impact on work or driving]; [Perioperative trajectory]
• Additional Presurgical Workup: [Language or memory lateralization studies or other evaluations that may be informative] (Defer specifics to surgical team. Include only if applicable.)

Decisional Capacity Assessment

(Include this section only if capacity evaluation was performed or specifically requested. Omit entirely if not indicated.)

Decision(s) Evaluated: [Consent to surgery / ability to weigh risks and benefits / adherence to postoperative restrictions / DBS device management / other]

• Understanding: [Ability to comprehend relevant information about the procedure, risks, benefits, and alternatives]
• Appreciation: [Recognition of how information applies to own situation and circumstances]
• Reasoning: [Ability to compare options, weigh consequences, and provide rationale for choice]
• Expression of Choice: [Ability to communicate a stable, consistent decision]

Supports to Enhance Capacity: [Teach-back methods, simplified materials, caregiver involvement, interpreter services]

Capacity Conclusion: [Clear conclusion specific to the decision(s) at hand, not a global competence statement; if capacity cannot be adequately determined, document limitations and recommended next steps such as targeted capacity interview, ethics consultation, or psychiatric stabilization]

Recommendations

(Provide concrete, actionable recommendations. Specify responsible party when appropriate.)

Pre-Procedure

• [Mood or behavioral optimization and referrals]
• [Cognitive strategies and environmental supports to implement]
• [Caregiver involvement and education planning]
• [Work or school accommodations]

Peri-Procedure

• [Inpatient communication supports]
• [Delirium prevention strategies] (Include when relevant)
• [Medication management considerations]

Post-Procedure

• [Follow-up neuropsychological testing timeline and indications for earlier reassessment]
• [Rehabilitation referrals: cognitive rehabilitation, speech-language pathology, OT/PT]
• [Safety considerations for driving and workplace hazards, consistent with treating physician guidance and local regulations]
• [Ongoing mental health treatment and supports]

Limitations

(Include only if material limitations apply; omit section if none.)

[Incomplete records]; [Language or cultural considerations]; [Fatigue, pain, or sleep issues]; [Medication effects]; [Sensory or motor limitations affecting testing]; [Validity concerns]; [Telehealth constraints]

Signature

[Electronic signature with credentials, date, and time per institutional policy]

Appendix A: Tests Administered by Domain

(Optional. List tests organized by domain without proprietary item content.)

Appendix B: Score Summary Table

(Optional. Include standardized scores, percentiles, and qualitative descriptors.)

Appendix C: Normative and Interpretive Conventions

(Optional. Describe normative sources, demographic adjustments, and qualitative descriptor conventions.)