Provides a summary of a neuropsychological assessment session, organising information about the client’s presentation during testing, mental status, tests administered and behavioural observations during the assessment, to assist with the preparation of a report.
This template can be used in conjunction with NovoNote’s Neuropsychology Pre-Assessment Interview and Neuropsychology Feedback Session templates. These may then be integrated into a Neuropsychological Assessment Report template, along with psychometric results in NovoPsych, via “Create Document”.
Mental Status Examination (MSE)
Provide a narrative summary of the client’s mental status during the assessment session, including appearance, behaviour, speech, mood and affect, thought process, thought content, perception, cognition, and insight and judgment.
Test Session Context
Describe the testing environment and any factors that could affect test performance. Note the client’s physical state, use of assistive devices, medications taken, level of alertness, breaks taken, and testing session duration.
Tests Administered
List all neuropsychological tests and assessment measures administered during this session in order. Note any modifications to standard administration procedures or tests attempted but not completed.
General Observations
Describe the client’s general approach to the assessments, including motivation, effort, cooperation, understanding of instructions, awareness of performance, work style, test anxiety, and any behavioural changes during the session.
Observations
For each test administered, provide specific behavioural observations that could impact interpretation of results. Document strategies used, error patterns, response to success and failure, emotional responses, unexpected strengths or weaknesses, and discrepancies between subjective report and objective performance.
Effort and Validity Considerations
Document observations related to effort and engagement, results of performance validity measures, inconsistencies in performance, external factors impacting performance, and client statements about effort or engagement.
Client’s Self-Report During Testing
Document spontaneous comments about performance or cognitive functions, reported symptoms, subjective experience of tests, connections to real-world difficulties, and insights about cognitive strengths and weaknesses.
Physical and Sensory Observations
Document observations about fine and gross motor functioning, tremors or coordination difficulties, sensory difficulties, handedness, pain behaviours, and fatigue or energy changes.
Additional Clinical Observations
Document observations about emotional state, anxiety or frustration, issues with arousal or attention regulation, unexpected events, and other clinically significant observations.
Preliminary Impressions
Document any preliminary clinical impressions reported by the clinician.
Next Steps
Document planned next steps, including additional testing sessions, specific domains requiring further assessment, feedback session plans, tests planned for future sessions, information or records requested, immediate feedback provided, and any referrals made.
Session Summary
Provide a concise summary of the assessment session, including overall presentation, key tests administered, significant behavioural observations, and critical next steps.
Mental Status Examination (MSE)
Mary presented as well-groomed with cooperative behaviour throughout testing, though appeared mildly anxious initially. Her speech was normal with clear articulation. She described her mood as “worried about how I’ll do” with congruent affect. Thought processes were coherent with no evidence of thought disorder or perceptual disturbances. Mary was fully oriented with intact basic cognitive functions but demonstrated difficulty with sustained attention. She showed good insight into her cognitive difficulties and assessment purpose.
Test Session Context
Testing was conducted in a quiet office environment. Mary reported feeling physically well though mentioned some fatigue from recent shift work. She wore prescription glasses with no hearing difficulties. No medications were taken on testing day. Mary remained alert throughout the 3-hour session with two brief breaks.
Tests Administered
General Observations
Mary approached assessment with good motivation and consistent effort. She understood instructions readily with minimal repetition needed. Mary showed awareness of performance difficulties, particularly on timed tasks, expressing frustration with slower processing. Her work style was careful and methodical with mild initial test anxiety that resolved as testing progressed.
Observations
During WAIS-IV, Mary performed well on verbal tasks but struggled with processing speed subtests. On memory tasks, she used verbal rehearsal strategies but had difficulty with visual-spatial items. Trail Making Test revealed careful, deliberate approach with self-monitoring. Mary expressed frustration with slower pace but persisted appropriately. Performance was consistent with reported daily functioning difficulties.
Effort and Validity Considerations
Mary demonstrated excellent effort throughout with no validity concerns. Performance was consistent across similar tasks and aligned with reported functional difficulties. No external factors negatively impacted performance beyond documented cognitive changes.
Client’s Self-Report During Testing
Mary frequently commented on perceived slowness, stating “This would have been easier before my accident.” She noted particular difficulty with multitasking and made connections between test items and work-related organisational challenges.
Physical and Sensory Observations
No significant motor or sensory difficulties observed. Mary used right hand for writing with adequate fine motor coordination. No tremors, coordination problems, or physical discomfort reported during session.
Additional Clinical Observations
Mary’s anxiety decreased as session progressed with good rapport maintained throughout. She showed appropriate emotional responses to challenging tasks with no significant arousal or attention regulation issues beyond expected fatigue during lengthy tasks.
Preliminary Impressions
Testing results appear consistent with mild cognitive impairment following traumatic brain injury, with primary deficits in processing speed and memory. Preserved verbal abilities and good effort suggest positive rehabilitation potential.
Next Steps
Results will be interpreted for comprehensive report preparation. Feedback session scheduled for 29/05/2025 to discuss findings and recommendations.
Session Summary
Mary completed neuropsychological testing with good effort despite mild anxiety. WAIS-IV, WMS-IV, and Trail Making Test results revealed processing speed and memory difficulties consistent with reported functional changes. Her preserved verbal abilities suggest good rehabilitation potential, with comprehensive feedback session scheduled.
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