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. 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
Notes / chart reviewed
Role explained
Previous sessions completed
Session objective / purpose
Client perspective
Family perspective
Consent for the assessment to be completed
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.
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.
A concise explanation is key - tailored to the session objective.
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.
I.e. ‘Kitchen assessment completed 23.04.14 – 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. If the full summary
of the assessment is available including a breakdown of scores by
category consider listing these also as a comparison.
I.e. ‘MoCA completed August 2012 – score 26/30’.
MoCA cognitive screening assessment.
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.
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.
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
Occupational Performance
Issues (OPI’s)
Analysis
Plan
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)
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).
Key issues identified and proposed solutions to the OPI’s.
I would also document there if the patient / family agree and
consent to your proposed solutions / recommendations.
Demonstrate your clinical reasoning in this section – no new
information in this section – should have a logical flow through the
entry.
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.
I.e. OT has significant concerns with patients ……… relating to …….
However patient / family has chosen to exit the OT service OR has
declined OT recommendations for ……….. 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)
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.