Neuropsychological Evaluation Sample Report

Neuropsychological evaluation is the process of determining the individual’s psychological and mental health or condition. It reviews the basic components of a clinical neuropsychological report and demonstrates how to tailor findings, recommendations, and conclusions to specific audiences, including referring physicians, school professionals, and legal decision makers. It is used by healthcare providers, educators, courts, and law enforcement to aid in the detection and treatment of criminals, improve education and counseling, identify developmental disorders, and evaluate work performance.

Table of Contents

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There are many different types of neuropsychological assessment. There are several areas that require the use of these assessments during the screening and assessment process for individuals, families, and institutions. In order to properly evaluate individuals and families, there needs to be a written evaluation that documents what the person has experienced and that discusses his/her behaviors, experiences, strengths, and weaknesses. A self-report form may also be utilized during neuropsychological assessment when discussing specific issues or addressing concerns that may arise from a thorough screening.

In most instances, the clinical team will begin with a self-profile questionnaire. This form asks a series of questions designed to gather information on personal issues that may relate to the individuals or families under evaluation. Questions may include demographics (age, gender, race, ethnicity, socioeconomic status), medical history (diagnosis, and medication), life goals, beliefs, and personal aspirations. The sample report will then review and gather all information on the patient and his/her caregivers in order to create an accurate depiction of the patient’s current situation, what the future might hold, and how to address current issues and potential problems.

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Often times, multiple samples are needed in order to create an accurate diagnosis. When this is the case, the service provider will collect data on the dimensions used to assess the individual, as well as information from other sources. These sources may include educational and professional history of the patient, the work environment and relationships at home and at work, siblings, neighbors, workplaces, and any personal characteristics that may contribute to the patient’s distress. After developing the needed information, a report will be developed. The length of the report will vary based on the patient and the service provider collecting the data.

The Neuropsychological evaluation may be written, but it can also be oral. If oral gathering of data is necessary, a small-written version of the sample will be useful. The verbal format allows the neuropsychologist to include information that is specific to the patient, drawing upon previous experience. In addition, the sample report should be structured to be easy to understand. Drafting a report in plain English will make it easier to remember, which will increase the likelihood that the patient will engage with the information and utilize it to make treatment decisions.

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Once a standard sample has been created, the service provider may begin the verbal or written portion of the assessment. The length of this portion will depend upon the service provider and the type of information needed. In some cases, several patients may be involved, and the length of the assessment will need to reflect this. If there are several therapists involved, each may require a different length of time for the assessment.

During the verbal portion of the assessment, the therapist will review and explain the diagnostic processes involved. Based on the NPI number, specific issues will be considered for improvement and correction. Sometimes these are minor changes to daily routines, but may be a difference as minor as wearing the same shoes for longer hours instead of walking barefoot. In other cases, patients may be required to perform more difficult tasks or sit in uncomfortable positions for extended periods of time. Other times, the patient may be asked to perform tasks while sitting still, such as picking up objects off of a shelf or writing.

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The last portion of the sample report will include comments regarding the service provider’s professional conduct and style. Specifically, the focus will be on the areas that were reviewed during the screening process. If the sample is not large enough, feedback can be from one therapist to the next. Regardless of the results of Neuropsychological evaluation, a report is always provided for review within a short period of time.