Test Administration/Scoring Log (Psychological/Neuropsychological)

Patient Name: [Patient name]

DOB: [Date of birth]

MRN: [Medical record number]

Date(s) of Service: [Date(s) testing/scoring occurred]

Referral Question/Indication: [Brief one-sentence indication for evaluation]

Referring Clinician: [Name, degree, service]

Evaluation Type: [psychological / neuropsychological]

Setting: [outpatient clinic / inpatient / school / forensic / other]

Modality: [in-person / telehealth / hybrid / computer-administered]

Personnel

• Responsible Clinician: [Name, credentials, role]
• Administrator(s):
  • [Name, credentials, role] (List each person who administered tests; add separate bullet per person. Omit if same as responsible clinician.)
• Scorer(s):
  • [Name, credentials, role] (List each person who scored tests; add separate bullet per person. Omit if same as administrator.)
• Supervision: [Supervision model and supervisor name/credentials] (Include only if technicians or trainees involved; otherwise omit.)
• Interpreter: [Name, language, modality] (Include only if interpreter was used; otherwise omit.)
• Third-Party Observers: [Name/relationship, purpose, proximity to examinee] (Include only if present; otherwise omit.)

Test Administration Log

(Add one row per test administered. Do not include tests considered but not administered. Do not include raw scores, item content, or stimulus materials.)

Test Name (full name and abbreviation)	Edition/Form/Version	Domain	Administration Method	Administrator	Time (start/stop or total minutes)	Standardization	Scorer	Scoring Time (min)	Status	Notes Flag
[Test full name (Abbrev)]	[Edition/form/version]	[Domain assessed]	[clinician-administered / technician-administered / computer-administered / self-report / informant report]	[Administrator name]	[HH:MM–HH:MM / total minutes]	[standard / accommodated / modified]	[Scorer name]	[Minutes]	[completed / partial / discontinued / invalidated / pending]	[Y / N]

(If critical fields—administrator, edition/form, standardization, or time—were not recorded contemporaneously, mark as "Incomplete—requires completion before finalization.")

Accommodations

[Standard administration procedures used; no accommodations or modifications.] (Replace with details below if accommodations or modifications were used.)

• What changed: [Operational description of accommodation/modification]
• Why: [Functional limitation or situational need]
• Tests affected: [List specific tests]
• Classification: [accommodation / modification]
• Expected impact on interpretability: [Effect on norms or validity, e.g., "timed norms may not apply"]

(Repeat the above structure for each distinct accommodation or modification used.)

Testing Irregularities

[No testing irregularities noted.] (Replace with details below if irregularities occurred.)

• What happened: [Objective description with timestamp if available]
• Tests affected: [List specific tests]
• Mitigation attempted: [Actions taken to address the irregularity]
• Preliminary impact statement: [Potential effect on validity]

(Repeat the above structure for each distinct irregularity. Categories include: environmental disruption, patient factor, administrative deviation, technical failure.)

Behavioral Observations

[Brief operational observations relevant to test-taking behavior: engagement/effort, comprehension of instructions, motor/sensory constraints, response style relevant to validity] (Do not include diagnostic impressions or detailed test results. This section contextualizes administration quality only.)

Time Summary

• Total Administration Time: [Minutes] (If not recorded, enter "Not recorded—requires completion before finalization.")
• Total Scoring Time: [Minutes] (If not recorded, enter "Not recorded—requires completion before finalization.")
• Clinician Direct Time: [Minutes]
• Technician Time: [Minutes] (Include only if applicable.)
• Computer-Administered Time: [Minutes] (Include only if applicable.)

Per-Day Totals

(Include this table only if testing spanned multiple days; otherwise omit.)

Date	Administration Time (min)	Scoring Time (min)	Administrator(s)	Notes
[Date]	[Minutes]	[Minutes]	[Name(s)]	[Optional notes]

Billing Date of Service: [Date used for billing] (Include only if multi-day testing.)

(Time must reflect actual time spent; do not estimate.)

Data Storage

Storage Location: [EHR media tab / locked file room / testing platform / other]

Recordings: [No recordings made. / Description of recordings and storage location]

(Do not include test items, stimulus images, or proprietary scoring materials in this log.)

Attestation

Tests were administered and scored following standardized procedures unless otherwise documented above. Deviations, accommodations, and irregularities are recorded and will be considered in interpretation.

Printed Name	Credentials	Role	Signature	Date
[Name]	[Credentials]	[Administrator / Scorer / Responsible Clinician]	______________________________	[Date]

(Add additional signature rows for each person who administered or scored tests.)