An example of writing up a cognitive screen and …

1 Disclaimer: the above material is purely for teaching purposes and clinicians must use their own clinical reasoning / judgement before applying this in a real world setting. An example of writing up a cognitive screen and linking it to occupational performance: Often in physical settings OT s will be asked to assess cognition and make recommendations on a patient s safety to return home this is quite a thorny area for us historically! The way I see it is that our role is to assess Occupational Performance and to provide recommendations on how to meet our patient s needs.

2 In this type of case it could be done through a combination of a cognitive screening assessment and a functional / occupational based assessment . Most organisations have specific policies / practices around whether or not OT s complete cognitive screening assessment so is best to check with your supervisor / senior etc. before delving into this area! This example uses the montreal cognitive assessment ( moca ) which is a free cognitive screening assessment combined with a functional assessment . The format used builds on the general notes hand out found here. Consent Consent for the assessment to be completed Notes / chart reviewed Reviewing notes prior to the session is very important, consider stating that observations were stable for treatment if working in a medical setting where patient s medical status may fluctuate or be precarious.

3 Before completing a cognitive screen consider if the patient has an active infection and whether this is likely to slant / effect the results of the assessment . Role explained A concise explanation is key - tailored to the session objective. Previous sessions completed If I am doing an assessment like a cognitive screen I would cite my previous entries to link them in the patient assessment journey with OT. Kitchen assessment completed see entry for full assessment details . If the patient has completed multiple cognitive assessments before this session I would also cite the scores and dates of these assessments to link them / show progression.

4 If the full summary of the assessment is available including a breakdown of scores by category consider listing these also as a comparison. moca completed August 2012 score 26/30 . Session objective / purpose moca cognitive screening assessment . Client perspective Anything the patient reports to you Ask the patient if they feel that they have any problems with their memory if yes then what types of things do they forget / struggle with / what effect does this have on their daily life, has their family expressed any concerns with their memory etc. Family perspective This can be helpful is much of the information that s given is from family or contradicts what the patient reports to you, or if the family have specific concerns about the patient.

5 Disclaimer: the above material is purely for teaching purposes and clinicians must use their own clinical reasoning / judgement before applying this in a real world setting. Occupational Performance I would typically write up the assessment as follows: assessment : montreal cognitive assessment ( moca ) (write assessment name out in full) Form is filed overleaf / in rear of notes etc. Patient score: xx/30 (state if patient gained a point due to years of formal education) Scored as follows: Visuospatial / executive x/5 (add qualitative information if appropriate like if they struggled with a particular question) Naming x/3 (report wrong answers) Memory (not formally scored but report any difficulties with this) Attention Number repetition x/2 - Letter repetition x/1 - Serial maths question x/3 Language Sentence repetition x/2 - Fluency x/1 (see marking sheet for acceptable word types) Abstraction x/2 (ensure that you consult the marking sheet for acceptable answers)

6 Delayed recall x/5 (include qualitative information if appropriate) Orientation x/6 (include detail of points missed) Patients perception of assessment performance (ask the patient how they thought it went what did they find difficult etc.) Occupational Performance on the ward at present: (describe ADL abilities as observed on ward or any behavioural concerns of relevant cite any notes entries regarding this) and contrast with requirements for patients safe return to normal residence). Occupational Performance Issues (OPI s) Key issues identified and proposed solutions to the OPI s.

7 I would also document there if the patient / family agree and consent to your proposed solutions / recommendations. Analysis Demonstrate your clinical reasoning in this section no new information in this section should have a logical flow through the entry. Plan Particularly with patients where cognition is a concern it is important to document if the patient is likely to be discharged against your advice or despite your concerns that this is clear. OT has significant concerns with patients .. relating to .. However patient / family has chosen to exit the OT service OR has declined OT recommendations for.

8 And appears to understand the potential risks of doing so. Also document if you are planning to discuss the outcome of the assessment with other MDT members / medical team (a separate entry should be made with content of those discussions)