SPRINGER REFERENCE Jeffrey S. Kreutzer John DeLuca Bruce Caplan Editors Da VO lence mes Clinical Neuropsychology Second Edition a SpringerNewropsy chological Report ‘Sobilberg, M.M, & Mater, C.A.(2001). Cogaitive reha- bidation An iniegraive — newopsychological approach. New York: The Guilford Pres. ‘Wibon, B. (2004). Theoretical te cognitive rehabilitation. In LH. Goldstein & J. E McNeil (Eds), Clinical nearpmychalogy: A practical guide to ameument anf omunagemens far cloeisns (pp. 345-366). London: Wiley. Wikon, B. A. (2008). Newupsychological retahiltation, Annual Review of Clinical Prychology, 4, 141-162. Wikon, BA, Gmecy, F, Evins 1 J., Neuropsychological Report ‘Molly E, Zimmerman of Psychology, Fordham University, Bronx, NY, USA Definition Following the completion of a neurpsychological asscssment, a nouropsychological report is gener ated to communicat: the findings of the evaluation, Current Knowledge ‘Neuropsychological reports should clearly sum- marize the results in amanner that is both useful to, the paticnt and to the refimal source (e.g, the patient's primary care physician) (Strauss et al. 2006), The language usod in the report should be ‘concise, Itis important to keep in mind that poten- tial readers of the report include not only the patients and their families but the referral source and other healthcare professionals, Excessive jar gon, acronyms, and technical terms should be avoided or used sparingly. It is often preferable to refer to the patients by their given name throughout the report (Hebben and Milberg, 2002), The typical overall format and length of the report vary greatly and should be determined, ‘on the basis of the assessment setting, needs ofthe referral source, and nature of the presenting prob- Jem. In general, however, brevity and charity are favored over lengthy and broad elaborations on 2435 specific details. In some settings, a single-page reportis sufficient, while in ather settings, multiple pages are necessary to most effectively communi cate the findings. Reports should be well organized and casy torcad. It is important to include only that information in the report which is relevant to the reform quostion and to the patois presenting presenting ‘complaint. Provision of imekvant information may be considered an unduc invasion of privacy, according tothe American Psychological Associa tion Ethical Principles of Psychologists and Code ‘of Conduct (2002; Principle 4.04), Avoid reférence to a third pany unless it is absolutely relevant ‘information for the conceptualization of the find- ings. Ifit is necessary to include the name of athird. party, a medical release of information should be obtuined from that individual (Stramssetal. 2006). Asa general mule, reports should be written as soon as possible following the evaluation (Hebben and. ‘Milberg 2002). The typical content of a neuropsy- chological report is also likely to vary between clinicians andsetings, However, most reports con- tain the following basic information (adopted from ‘Strauss ct al 2006; Hebben and Milberg 2002): 1, Identifying information. Reports should con- tain information that efficiently identifies the patient. This generally includes the patient's full name, date of birth, age, date of the eval uation, date of the report, and referral source. 2. Reason for referral. The goal of the assess- mentand reason firreferral should be explic- itly stated in the beginning of the report. This statement serves as an indicator ta the referral source that you have understood the referral question, and it provides a contoxtfor the inter pretation of findings and recommendations. 3. Relevant history. Bricfly summarize relevant information regarding the patient's medical 4. Relevant previous reports, Bricfiy summarize relevant medical reports, school reports, or previous evaluations, 5. Patient concems. Provide a historical descrip tion of the patient's concems, or lack thereof, reganding their current physical, emotional, and‘cognitive state. It is possible that the patient's ‘concerns may be quite different from those of the referral soune, and, if this is the case, it is ‘Important to deacribe these differences. Behavioral observations. During the neuro psychological assessment, the clinician will have the opportunity to observe many differ- ent aspects of the patient’s behavior, In this section of the report, the patient's personal appearance, rapport with the examiner, appmach to assessment, ability to persist, and cooperativences should be described. 7. Test results. Although the format of this sec- tion may vary, typical reports will describe findings by cognitive domains, Some reports will briefly summarize findings in one to two paragraphs, while other reports will describe findings in more detail using a paragraph for each cognitive domain. It is important to emphasize both the strengths and weak- nesses. Performance is froquently character- ized by descriptive Inbels (¢g., “average.” “superior” ), and sonres are expressed as per- centiles or standardized scores. At times, it may be appropriate w include mw scores as well. This section should be introduced with an explanation of the metric used for the description of performance w ensure compre- hension of the findings by all potential readers of the report. Performance should be described using objective teminology. ‘Summary and impressions. A brief synopsis of the patient's history, presenting problem, and referral question offen serves as the beginning of this section of the report. Inter- pretation of major neuropsychological find- ings and a diagnostic statement arc critical components of the summary. If passible, include a statement addressing the potential stiology of any obscrved deficits as well as Prognosis. The format of this section is typi- ally bulleted or in a brief paragraph farm, ). Recommendations. Relevant mcommenda- ‘tons based on a synthesis of the test results and interpretation are often usefill to the refer- ral source for the delivery of services, devel- opment of treatment plans, and direction of additional referrals, if necessary. This section Newtopsychological is frequently presented in a bulleted or brief paragraph form, 10. Tests administered, Many neuropsych: cal reports include a list of the full names and versions of the tests that were admins- tered during the assessment. If desired, per- formance may be described as well, with appmpnate descriptions of the mete used. ‘to characterize the scores. ‘Cross-References » Effort » Standard Scores » T Scores » Test Interpretations: Computer Based » ZScores References and Readings American Prychalogical Asiociation, (202). Eénical prin ciples of psychologists and code of cmduct American Paychologist, 57, 1060-1073. Medien, N., & Millerg, W. 2002). Emeniial of newn- pachalogical aressment. New Yori: Wiley. ‘Stmups, E., Sherman, EM. S, & Spreen, Q. (2006). 4 campendium of neumpaychalagical rear Adminisrs- ‘tom, norms, and commeniary. O-xfard: On ford Univers sity Press. Neuropsychological Screening Examination Glen E. Getz ‘Deparment of Psychiatry, Allegheny General ‘Thisisa bricf evaluation of onc orseveral areas of ‘cognitive functioning through the utilization of