DEMO COGNETIVE ASSESMENT 10 PAGES

dummy ROUTE SHEET
COGNITIVE ASSESSMENT
Full name
Patient Name
Signature
Signature
Date of Service

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
Address
Patient's Signature
Date

MonthDayYear
Date
Authorized Person's Signature:
Name of Signatory
Date

MonthDayYear
Date
Signature over Printed Name
Date

MonthDayYear
Date
MEDICATION RECONCILIATION
Patient Name
Date of Service

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Sex:

MF
Pharmacy
Phone
Format: (000) 000-0000.
Drug Allergies
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
26.
10.
NEW PRESCRIPTION / MODIFICATIONS / TO BE DISCONTINUED (STATE REASON FOR CHANGE)
NEW PRESCRIPTION / MODIFICATIONS / TO BE DISCONTINUED (STATE REASON FOR CHANGE)
DATE

MonthDayYear
Date
Patient Name
Date of Service

MonthDayYear
Date
Age
Age:

TELEHEALTHHOME VISIT
Age:

Is patient able to provide a complete and reliable medical history? Yes No Is an independent historian present that can provide a complete and reliable medical history? Independent historian is (name and title):Yes
Date of Birth

TempVITALSHeightWeightft inlbsBMIAge:
Date of Birth

Date of BirthPatient Name:Sex:Date of Service:COGNITIVE ASSESSMENT VISITDate of BirthDate of BirthDate of BirthDate of BirthDate of BirthDate of BirthDate of Birth
Date of Birth

Date of BirthDate of BirthDate of BirthDate of Birth
Date of Birth

MonthDayYear
Date
Sex:

MF
Sex:

RRNo
Sex
Sex
Is patient able to provide a complete and reliable medical history? Yes No Is an independent historian present that can provide a complete and reliable medical history? Independent historian is (name and title):
Height
ft in
Weight
Weight
BMI
Temp

COGNITIVE COMPLAINTBathing Grooming Shopping Meal preparation Do laundry Do housekeepingHR
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BPO2 Sat
Temp
BP
HR
O2 Sat
COGNITIVE COMPLAINT
DETAILED HISTORY OF COGNITIVE IMPAIRMENT
SAFETY & SOCIAL SUPPORT

Cane NoWalker YesCrutches Name & title:WheelchairDETAILED HISTORY OF COGNITIVE IMPAIRMENT
Is patient bedbound? No Yes Does patient use an assistive device? No Does patient have social support at home? Is patient’s social support knowledgeable of, and understands patient’s illness? Is patient’s social support willing to provide the care that patient requires? Does patient’s social support require education / training? Does patient require additional social support? No Yes, explain:
Crutches Name & title:

Is patient bedbound? No Yes Does patient use an assistive device? No Does patient have social support at home? Is patient’s social support knowledgeable of, and understands patient’s illness? Is patient’s social support willing to provide the care that patient requires? Does patient’s social support require education / training? Does patient require additional social support? No Yes, explain:EVALUATION FOR HOME AND MOTOR VEHICLE OPERATION
No Some Yes No Some Yes
No Some Yes

Decreased flexibility, strength and balance Slowed speed of processing Confusion / Disorientation Impaired ability or unsafe to drive Declines in aspects of cognition that impact working and/or memory Decreased basic and complex attention skills Compromised Mental Status Other:ASSESSMENT OF BASIC AND INSTRUMENTAL ACTIVITIES OF DAILY LIVING:
No Some Yes
Decreased flexibility, strength and balance Slowed speed of processing Confusion / Disorientation Impaired ability or unsafe to drive Declines in aspects of cognition that impact working and/or memory Decreased basic and complex attention skills Compromised Mental Status Other:
ASSESSMENT OF BASIC AND INSTRUMENTAL ACTIVITIES OF DAILY LIVING:
Patient is unable to independently do the following:
Bathing Grooming Shopping Meal preparation Do laundry Do housekeeping

SAFETY & SOCIAL SUPPORTDressing Hygiene Toileting Feeding self Continence(bladder/ bowel) Transfer in and out of bed or chairPatient is unable to independently do the following:
Dressing Hygiene Toileting Feeding self Continence(bladder/ bowel) Transfer in and out of bed or chair

No Some Yes No Some YesHandle own medication Handle finances Patient is independent in all ADLs Other:No Some Yes
Handle own medication Handle finances Patient is independent in all ADLs Other:
COGNITIVE ASSESSMENT VISIT
Patient Name
Date of Service

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
Sex:

MF
DEPRESSION SCREENING

Patient is unable to answer
Mark each question with the appropriate number. When completed, see recommendation based on total.
Mark each question with the appropriate number. When completed, see recommendation based on total.

0 No Depression 1-4 Minimal depression 5-9 Mild depression10-14 Moderate depression (suggest referral to mental health) 15-21 Moderate to severe depression (recommend referral to mental health)TOTAL1 Little interest or pleasure in doing things 2 Feeling down, depressed or hopeless 3 Feeling tired or having little energy 4 Poor appetite or overeating 5 Trouble falling or staying asleep, or sleeping too much 6 Feeling bad about yourself or that you are a failure or have let yourself or your family down 7 Trouble concentrating on things, such as reading or watching tv 8 Moving or speaking so slowly that other people noticed or being so fidgety or restless that you have been moving a lot more than usual 9 Thoughts that you would be better off dead or of hurting yourself in some wayOver the last 2 weeks, how often have you been bothered by any of the following problems? Not at all = 0 Several days = 1 More than a week = 2 Nearly every day = 3
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ANXIETY SCREENING
ANXIETY SCREENING

Patient is unable to answer
Mark each question with the appropriate number. When completed, see recommendation based on total.
Mark each question with the appropriate number. When completed, see recommendation based on total.
More than a week = 2

0 No Anxiety 1-4 Minimal Anxiety 5-9 Mild Anxiety10-14 Moderate Anxiety 15-21 Severe AnxietyTOTAL1 Feeling nervous 2 Not being able to stop or control worrying 3 Worrying too much about different things 4 Trouble relaxing 5 Being so restless that it’s hard to sit still 6 Becoming easily annoyed or irritable 7 Feeling afraid, as if something awful might happenOver the last 2 weeks, how often have you felt the following? Not at all = 0 Several days = 1
COGNITIVE ASSESSMENT VISIT
Patient Name
Date of Service

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
Sex:

MF
PATIENT EXAMINATION MINI-COG (if patient is not capable of answering, proceed to AD8)

Patient is unable to answer
Step 1: Word Registration:
“Please listen carefully, I am going to say three words that I want you to repeat back to me now and try to remember. The wordsare: (select a version below Please say them back to me now” (If patient is unable to repeat the words back, then move on to clock drawing)
Version 1
Version 2
Version 3
Version 4

Red Banana Fish

Rows	Word 1	Word 2


Word 3

Step 3: Clock Drawing:

Rows	“Next I want you to draw a clock for me. Please put all of the numbers where they go	“Next please draw the hands to show 10:15

Step 4: Information

“Can you tell me something that happened in the news recently or something that you did last week?

Rows	CORRECT INCORRECT	If patient scores 9 correctly, no significant cognitive impairment and further testing is not necessary. If patient scores 5 –8 correctly, more information required, proceed to AD8 Examination. If patient scores of 0 –4 correctly, Cognitive impairment is indicated, proceed to AD8 Examination.
“Do you know what year it is?
“Do you know what month?
“Do you know what day it is?

Step 5: Recall

“Can you tell me something that happened in the news recently or something that you did last week?“What were the 3 words I asked you to remember?
Version Used
COGNITIVE ASSESSMENT VISIT
Patient Name
Date of Service

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
M

Sex:F
AD8 DEMENTIA SCREENING INTERVIEW (Administered to either the independent historian, preferable, or the patient):

“YES, a change” indicates there has been a change in the last several years caused by cognitive (thinking and memory) problems.
YES,
NO,
N/A

A change

Rows	Problem with judgment (problems making decisions, bad financial decisions, problems with thinking)	No change	Don’t know

Less interest in hobbies / activities
Repeats the same things over and over (questions, stories or statements)
Trouble learning how to use a tool, appliance, or gadget (computer, microwave, remote control)
Forgets correct month or year
Trouble handling complicated financial affairs (balancing checkbook, income taxes, paying bills)
Trouble remembering appointments
Daily problems with thinking and/or memory

TOTAL AD8 SCORE
0 –1 “Yes”: Normal Cognition 2 or greater “Yes” or “Don’t Know”: Cognitive impairment is likely to be present
FUNCTIONAL ASSESSMENT STAGING TOOL (FAST)
STAGE

123456A6B
ASSESSMENT (score is highest consecutive level of disability)

No difficulties, either subjectively or objectively (normal aging)

Complains of forgetting location of objects; subjective word finding difficulties only (possible Mild cognitive impairment)

Decreased ability to perform complex tasks ex: planning dinner for guests, handling finances (possible Mild cognitive impairment)

Decreased job function evident to coworkers, difficulty in traveling to new locations (mild dementia)

Requires assistance in choosing proper clothing for the season or occasion (moderate dementia)

Difficulty dressing properly without assistance (moderately severe dementia)

Unable to bathe properly, may develop fear of bathing. Will usually require assistance adjusting bath water temperature (moderately severe dementia)
Inability to handle mechanics of toileting ex. Forgets to flush, doesn’t wipe properly (moderately severe dementia)

6C6D6E7A7B7C7D7E7F
Urinary incontinence, occasional or more frequent (moderately severe dementia)

Fecal incontinence, occasional or more frequent(moderately severe dementia)

Ability to speak limited to about half a dozen words in an average day (severe dementia)

Intelligible vocabulary limited to a single word in an average day (severe dementia)

Non-ambulatory –unable to walk without assistance (severe dementia)

Unable to sit up independently (severe dementia)

Unable to smile (severe dementia)
Unable to hold head up (severe dementia)
COGNITIVE ASSESSMENT VISIT
Patient Name
Date of Service

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
Sex:

MF
Clinical Dementia Rating
IMPAIRMENT
MEMORY

No memory loss or slight inconsistent forgetfulnessConsistent slight forgetfulness; partial recollection or events: “benign” forgetfulnessModerate memory loss; more marked for recent events; defect interferes with everyday activitiesSevere memory loss; only highly learned material retained; new material rapidly lostSevere memory loss; only fragments remain
ORIENTATION

Fully orientedFully oriented except for slight difficulty with time relationshipsModerate difficulty with time relationships; oriented for place at examination; may have geographic disorientation elsewhereSevere difficulty with time relationships; usually disoriented to time, often to placeOriented to person only
PROBLEM SOLVING
Solves everyday problems & handles business & financial affairs well; judgment good in relation to part performance

JUDGMENTSlight impairment in solving problems, similarities, and differencesModerate difficulty in handling problems, similarities, and differences; social judgment usually maintainedSeverely impaired in handling problems, similarities, and differences; social judgment usually impairedUnable to make judgment or solve problems
AFFAIRS
Independent function at usual level in job, shopping, volunteer and social group

COMMUNITYSlight impairment in these activitiesUnable to function independently at these activities although may still be engaged in some; appears normal to casual inspectionAppears well enough to be taken to functions outside a family homeAppears too ill to be taken to functions outside a family home
No pretense of independent function outside home
HOBBIES
Mild but define impairment of function at home; more difficult chores abandoned; more complicated hobbies and interests abandoned

HOMELife at home, hobbies, and intellectual interests well maintainedLife at home, hobbies, and intellectual interests slightly impairedOnly simple chores preserved; very restricted interests; poor maintainedNo significant function in home
Fully capable of self-care

PERSONALNeeds promptingRequires assistance in dressing, hygiene, keeping of personal effectsRequires much help with personal care; frequent incontinence
CARE
Requires assistance in dressing, hygiene, keeping of personal effects
Total Rating
0 .0 0.5 – 2.5 Questionable Cognitive Impairment 3.0 – 4.0 Very Mild Dementia

4.5 – 9.0 Mild Dementia 9.5 –15.5 Moderate Dementia 16.0 –18.0 Severe Dementia
COGNITIVE ASSESSMENT VISIT
Patient Name
Date of Service

MonthDayYear
Date
Age

Patient’s cognitive health in general: Poor Fair Good Very Good ExcellentPLAN AND MANAGEMENTGOALPROBLEMSex:
Age
Date of Birth

MonthDayYear
Date
Sex:

MF
CASE SUMMARY
PROBLEM
GOAL
PLAN AND MANAGEMENT
COGNITIVE IMPAIRMENT DIAGNOSIS(ES) WITH ICD-10 CODES

Alzheimer's disease (G30.9)Dementia (F03.90)Dementia with behavioral disturbance (F03.91)Memory loss (G31.84)
COGNITIVE ASSESSMENT VISIT
Patient Name
Date of Service

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
Sex:

MF
ADDENDUM
COGNITIVE ASSESSMENT VISIT
Patient Name
Date of Service

MonthDayYear
Date
Age
Age

Neurologist
Age

Psychiatrist
Age

Adult Day Care
Age

Home Health
Age

Social Worker
Age

Other:
Age
Date of Birth

MonthDayYear
Date
Date of Birth

Medical Management
Date of Birth

Speech Therapist
Date of Birth

Occupational Therapist
Date of Birth

Home Health Aide
Sex:

MF
REFERRAL & ORDERS

Behavioral Therapist / Psychologist
Neurologist
Behavioral Therapist / Psychologist
Psychiatrist
Adult Day Care
Medical Management
Social Worker
Speech Therapist
Occupational Therapist
Home Health Aide
DATE
DATE

MonthDayYear
Date
Patient Name
Date of Service

MonthDayYear
Date
Age
Age

I understand that the Federal Patient Self-Determination Act of 1990 requires that I be made aware of my right to make Healthcare decisions for myself. I understand that I may express my wishes in various documents so that my wishes may be known when I am unable to speak for myself or make decisions on my own.Phone #
Date of Birth

MonthDayYear
Date
Sex:

MF
it with my family, friends, caregivers, and/or medical practitioners.

I refuse to discuss / I wish to defer for future visits.I have thought about what medical treatments I would want in the event I am unable to speak for myself and have discussedI have thought about Physician Orders for Life-Sustaining Treatment (POLST)This plan reflects my wishes and details my goals for my treatment and care.
it with my family, friends, caregivers, and/or medical practitioners.

I have Name:havenot completed an Advance Directive. A copy can be obtained from: Relationship:
it with my family, friends, caregivers, and/or medical practitioners.

I have Name:havenot completed a living will. A copy can be obtained from: Relationship:
I have Name
havenot completed an Advance Directive. A copy can be obtained from: Relationship
Phone #

it with my family, friends, caregivers, and/or medical practitioners.Phone #
Phone #
Format: (000) 000-0000.
I have Name
havenot completed a living will. A copy can be obtained from: Relationship
Phone #
Format: (000) 000-0000.
Phone #

When I am dying, where practicable, I would prefer to be cared for at: My usual home A family member’s home Other: A hospice or palliative care unitIn a hospitalMy fears or worries about my future medical condition and medical care are:Preferred not to answerI would like these goals/specific wishes/requests to be achieved/come true:Phone #When I am dying, where practicable, I would prefer to be cared for at: My usual home A family member’s home Other: A hospice or palliative care unit
Phone #

When I am dying, where practicable, I would like the following treatments: Palliative care Stop medications which do not add to my comfort Stop medical interventions which do not add to my comfortComplementary and alternativetherapies: Attend to my spiritual needs: Preferred not to answer
I have person to make healthcare decisions on my behalf. A copy can be obtained from: Name: Relationship:
Phone #

I have person to make healthcare decisions on my behalf. A copy can be obtained from: Name: Relationship:havenot completed a health care proxy, health care power of attorney or otherwise nominated/elected/appointed a
Phone #
Format: (000) 000-0000.
I would like these goals/specific wishes/requests to be achieved/come true
I would like these goals/specific wishes/requests to be achieved/come true
I would like these goals/specific wishes/requests to be achieved/come true
My fears or worries about my future medical condition and medical care are
Complementary and alternativetherapies: Attend to my spiritual needs: Preferred not to answer
Complementary and alternativetherapies: Attend to my spiritual needs: Preferred not to answer
I would like the following life sustaining measures, if practicable: Cardiopulmonary resuscitation (CPR) Intravenous fluids Intubation and ventilation No life sustaining actions to be taken

I would like the following life sustaining measures, if practicable: Cardiopulmonary resuscitation (CPR) Intravenous fluids Intubation and ventilation No life sustaining actions to be takenArtificial feeding Antibiotics Blood transfusion and blood products Preferred not to answerAgeDate of Birth:Patient Name:Sex:Date of Service:ADVANCE CARE PLANNING (ACP)
I have the following requests to be carried out after I die: Organ/Body donation No Service Cremation Procession / Freeze-drying

I have the following requests to be carried out after I die: Organ/Body donation No Service Cremation Procession / Freeze-dryingChurch Service Ceremony Burial Preferred not to answerI have the following requests to be carried out after I die: Organ/Body donation No Service Cremation Procession / Freeze-dryingChurch Service Ceremony Burial Preferred not to answerI have the following requests to be carried out after I die: Organ/Body donation No Service Cremation Procession / Freeze-dryingChurch Service Ceremony Burial Preferred not to answerI have the following requests to be carried out after I die: Organ/Body donation No Service Cremation Procession / Freeze-drying
PATIENT’S SIGNATURE
DATE

MonthDayYear
Date
Signature
Should be Empty:

dummy ROUTE SHEET

COGNITIVE ASSESSMENT

MEDICATION RECONCILIATION

CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY

ASSESSMENT OF BASIC AND INSTRUMENTAL ACTIVITIES OF DAILY LIVING:

COGNITIVE ASSESSMENT VISIT

COGNITIVE ASSESSMENT VISIT

Step 1: Word Registration:

Version 1

Version 2

Version 3

Version 4

Step 4: Information

COGNITIVE ASSESSMENT VISIT

YES,

NO,

N/A

TOTAL AD8 SCORE

FUNCTIONAL ASSESSMENT STAGING TOOL (FAST)

COGNITIVE ASSESSMENT VISIT

Clinical Dementia Rating

IMPAIRMENT

PROBLEM SOLVING

AFFAIRS

HOBBIES

CARE

COGNITIVE ASSESSMENT VISIT

COGNITIVE ASSESSMENT VISIT

COGNITIVE ASSESSMENT VISIT

PATIENT’S SIGNATURE