Question template Flashcards
Outline
History Identifying information/reason for referral Assessment goals Patient’s goals and expectations? Patient’s understanding?
Presenting problems (cognitive, physical, psychological) Patient’s primary complaints
Onset and course
Records?
Functional status
Impact on activities of daily living for self-care?
Impact on higher-level functioning?
Past medical, and psychiatric, and substance use history
Medications
Family medical and psychiatric history
Academic History
Occupational History
Social History
Legal Issues/History
Collateral Report
Behavioural Observations
Testing Symptom validity Premorbid General ability Academics Attention and concentration Processing speed Language functioning Spatial processing Memory/new learning Executive function Sensory motor function Emotional/personality
Conceptualization
Identifying information and problem description:
Estimated premorbid intellectual functioning:
Performance/symptom validity:
Abilities within expectations based on estimate of premorbid functioning:
Deficits:
Inconsistent/equivocal finding:
Lateralization/localization of impairment:
Emotional state/personality traits:
Comorbid conditions that may affect cognition:
Diagnostic possibilities/rule outs
Likely:
Unlikely:
Recommendations
Additional work up:
Treatment and management:
Functional concerns:
Identifying information/reason for referral
- Age
- Marital status
- Handedness
- Primary language
- Race/ethnicity
- Focus assessment plan and interview
o Who is client; legal guardian?
Who referred, what are they hoping to gain from the assessment?
Other tests or to other clinicians, in addition to my assessment?
Assessment goals (if different from reason for referral)
Patient’s goals and expectations?
Patient’s understanding?
Presenting problems (cognitive, physical, psychological)
Patient’s primary complaints and why he has sought evaluation or treatment at this time.
Top one, two, or three concerns at the time of this assessment?
Onset and course of presenting problem(s)
Impact on patient’s life as a result of the problems? What has changed?
Has the course been worse, better, or staying the same?
Previous similar problems?
Do I have access to any medical records at this time? Specifically, X?
Functional status
Impact on activities of daily living for self-care?
Impact on higher-level functioning?
Past medical, and psychiatric, and substance use history
Recent medical events; hospitalizations?
Any chronic medical conditions?
Quality of health and medical adherence?
Family medical and psychiatric history
Anyone in the family with similar problems?
Academic History
What is the persons educational background? This information will help with determining expectations for performance?
Occupational History
What does or did this person do for a living?
Are they currently working?
Social History
Who does the patient trust and rely on most?
What is the family or collateral support liked for this person?
Legal Issues/History
Is the examinee involved in litigation; is there a significant legal history?
Collateral Report
I am curious if the collateral sources have the same complaints as the patient does?
Behavioural Observations
What is relevant about what I am thinking so far?
I am interested in mood and affect.
The interview suggests problems with executive function. Did the person behave appropriately?
Testing
Symptom validity Premorbid General ability Academics Attention and concentration Processing speed Language functioning Spatial processing Memory/new learning Executive function Sensory motor function Emotional/personality
