Cognitive Evaluation

HEDCO Clinic University of Oregon

Basic Information
Name / Birth Date / Today’s Date / Graduate Student Clinician
Date of most recent injury / Diagnosis / Referral source / Clinical Supervisor
Reason for referral:
Medical Background
Description of injury, initial symptoms and functional changes:
·  Include if there was any antero/retrograde amnesia post incident
·  Loss of consciousness post incident
·  History of prior head injury
Previous treatment and resulting impact:
Progression / resolution of symptoms after incident:
·  Current PCSS scores
·  Previous PCSS scores (date)
·  HIT score
Exacerbating factors:
Remediating factors (including management strategies):
Current medications and co-morbid conditions affecting functioning and performance:
·  Mental health difficulties (Anxiety, depression, bipolar disorder)
·  History of substance abuse
·  History of concomitant disorders/disabilities
Current concerns:
Educational/Vocational/Community Functioning
Living situation:
Primary support system:
Social/Recreational outlets:
History of learning disability, ADHD or other educational disability? / ☐ Yes ☐ No
Current Occupation/Responsibilities/Educational status:
Length of time in current occupation/career/as a student:
Current formal accommodations (if any):
Hours worked/in school per week:
Professional and personal goals:
Long term outcome
Short term goals
Current Primary Activities
(Current Classes) / Pre-Injury Performance Level (Pre-injury grade) / Current Performance Level (Current grade) / Strengths / Challenges / Currently Useful Strategies; Study Approaches or Supports
Describe accommodations, skills, or tools that would assist with identified concerns:
Cognitive-Communicative Functioning
Attention
·  Present results from objective testing (discuss subtests only pertaining to attention from RBANS; if TEA was administered then present results here) and tie them to subjective observations and client reports of how impairments impact daily activities/academic performance
·  Brief description of strategies utilized to address deficits and their effectiveness
Memory
·  Present results from objective testing (discuss subtests only pertaining to attention from RBANS) and tie them to subjective observations and client reports of how impairments impact daily activities/academic performance
·  Brief description of strategies utilized to address deficits and their effectiveness
Executive function
·  Present results from objective testing (discuss subtests only pertaining to attention from RBANS and/or D-KEFS; BRIEF; LASSI) and tie them to subjective observations and client reports of how impairments impact daily activities/academic performance
·  Brief description of strategies utilized to address deficits and their effectiveness
Social communication
·  Current challenges/changes (if challenges/changes exist, administer La Trobe Communication Questionnaire and report scores below, referring to Struchen et al., 2008 for scoring and interpretation)
Summary and Recommendations
Summarize and integrate the findings from both interview and testing to support recommendations and intervention plan.
(Refer to Appendix A for a detailed summary on test scores and interpretation)
Indicate whether you engaged in any prevention or educational counseling (prevention counseling: may include talking to client re: using helmets, seat belts; limiting or eliminating intake of alcohol, recreational drugs; monitoring engagement in high-risk behaviors)
Describe the client's endorsement of intervention approach.
Example: "Joe" endorsed intervention with direct attention training to address his desired outcome of improving his ability to read and retain content from textbooks.
Intervention Plan
Format: individual, group, or both
Frequency: number of sessions per week (Dosage typically one/two terms, TBD based on progress.)
Goal 1: target, approach and rationale (see example)
Target: Intervention will focus improving ability to read and retain content from textbooks using direct attention training
Approach: Direct attention training
Rationale: Direct attention training is intended to address working memory deficits at the level of impairment to boost the attentional system for a desired outcome.
Goal 2: target, approach and rationale
Goal 3: target, approach and rationale
Describe any plans for continued assessment or case coordination when indicated
Example: Intervention will be delivered in collaboration with a [mental health professional] to support psycho-social aspects of recovery.

______

Clinical Supervisor Graduate Student Clinician

Appendix A: Test Scoring and Interpretation Forms

Standardized Assessment Results
Cognitive Battery: Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
Index / Assessment / Description / Subtest score / Index score / Percentile rank / Interpretation
Immediate Memory / List
Learning / Measure of initial encoding, retaining and recalling simple and complex auditory information.
Story
Memory
Visuospatial/ Constructional / Figure Copy / Measure of basic visuospatial perception
Line Orientation
Language / Picture Naming / Measure of expressive language functioning.
Semantic Fluency
Attention / Digit Span / Measure of auditory sustained attention, visual selective attention, and processing speed.
Coding
Delayed Memory / List Recall / Measure of delayed recall and recognition for verbal and visual information.
List Recognition
Story Memory
Figure Recall
Composite score
Summary of RBANS:
Cognitive Battery: Selected Subtests of the Test of Everyday Attention (TEA)
Index / Assessment / Description / Subtest score / Index score / Percentile rank / Interpretation
Selective attention / Elevator Counting with Distraction / Measure of auditory selective attention
Alternating attention / Visual Elevator / Measure of alternating attention and cognitive flexibility in the visual and auditory modality
Elevator Counting with Reversal
Alternating attention (two modalities) / Telephone Search while Counting / Measure of alternating attention in visual and verbal modality.
Summary of TEA:
Cognitive Battery: Selected Subtests of the Delis-Kaplan Executive Function System (D-KEFS)
Assessment / Description / *When clinically significant BRIEF scores indicate the need for additional testing with D-KEFS tests, the student clinician will include relevant D-KEFS scores in the report in a suitably formatted table.
Color-word Interference / Assesses inhibitory control
Sorting / Assesses cognitive flexibility, problem solving, and concept-formulation
Twenty Questions / Assesses efficiency and perception of categories/sub-categories
Tower / Assesses problem-solving, spatial establishment / maintenance of instructional set
Summary of D-KEFS:
Rating Scale: Behavior Rating Inventory of Executive Function (BRIEF)
Scale/Index / Description / Raw Score / T Score / Percentile
rank
Inhibit / Assesses inhibitory control and impulsivity
Shift / Assesses the ability to move easily from one situation, activity, or aspect of a problem to another as the circumstances demand
Emotional Control / Measures the impact of executive function problems on emotional expression and assesses ability to control emotional responses.
Self-Monitor / Assesses aspects of social or interpersonal awareness.
Behavior Regulation Index (BRI)
Initiate / Reflects ability to begin a task or activity and to independently generate ideas, responses, or problem-solving strategies.
Working Memory / Measures the capacity to hold information in mind for the purpose of completing a task, encoding information, or generating goals, plans, and sequential steps to achieving goals.
Plan/Organize / Measures an individual’s ability to manage current and future-oriented task demands.
Task Monitor / Measures ability to keep track of problem-solving success or failure and identify and rectify mistakes when completing tasks.
Organization of Materials / Measures orderliness of work, living, and storage spaces.
Metacognition Index (MI)
Global Executive Composite (GEC) / Summary score that incorporates all of the clinical scales.
Summary of BRIEF:
Metacognitive awareness (Summary of the Self Awareness of Deficits Interview):
La Trobe Communication Questionnaire (LCQ)
Scale/Index / Self-rated score / Other-rated score
Initiation/Conversation Flow
Disinhibition/Impulsivity
Conversation Effectiveness
Partner Sensitivity
LCQ Total
Summary and interpretation: