Session Note Template:
For neuropsychologists providing feedback to a client following a comprehensive neuropsychological assessment. The template is designed to organise a summary of a session covering neuropsychological and psychometric results, any recommendations discussed, and the client/patient reaction, to assist with the preparation of a formal report.
This template can be used in conjunction with NovoNote’s Neuropsychology Pre-Assessment Interview and Neuropsychological Assessment Session templates. These may then be integrated into a Neuropsychological Assessment Report template, along with psychometric results in NovoPsych, via “Create Document”.
Mental Status Examination (MSE)
Provide a narrative summary of the client’s mental status during the feedback session, including appearance, behaviour, speech, mood and affect, thought process, thought content, perception, cognition, and insight and judgment regarding assessment findings.
Summary of Assessment Findings Discussed
Summarise the key neuropsychological assessment findings and psychometric results presented to the client. Include main cognitive strengths and weaknesses identified, diagnostic impressions shared, prognosis discussed, and how findings were explained. Note specific test results highlighted and how findings relate to presenting concerns and referral questions.
Reaction and Understanding
Describe the client’s emotional and cognitive reactions to assessment findings. Document their level of agreement or disagreement with results, questions or concerns expressed, understanding of diagnostic impressions, any misconceptions requiring clarification, level of insight demonstrated, and any change in perspective about their condition.
Recommendations Discussed
Detail specific recommendations presented during the feedback session. For each recommendation, note how it was explained, rationale provided, and client’s response. Categorise recommendations by type and document any prioritisation discussed, potential barriers identified, and solutions proposed.
Document specific action steps agreed upon for implementing recommendations, including responsibilities, timelines, progress monitoring, referrals to be made, resources provided, and any modifications made to original recommendations based on discussion.
Report Distribution
Document to whom the written neuropsychological report will be sent and consent obtained for information sharing. Note discussions about confidentiality, sections of report reviewed verbatim during session, and any requests for additional copies or specific providers.
Additional Support Provided
Describe emotional support, validation, or counselling provided during the feedback session. Document psychoeducation provided about the client’s condition, normalisation of experiences, reassurance provided, and emphasis on strengths and resilience factors.
Follow-up Plans
Document arrangements for planned follow-up appointments, agreed check-ins to monitor progress, plans for reassessment including timeline and purpose, and contingency plans for addressing new or worsening symptoms.
Client’s Questions and Concerns
List specific questions asked by the client and responses provided. Document concerns expressed about findings, recommendations, or future functioning, requested clarifications, and topics the client wanted more information about.
Session Summary
Provide a summary of the feedback session, including client’s overall response to findings, key recommendations discussed, significant action items agreed upon, and general tone and productivity of the session.
Mental Status Examination (MSE)
Mary presented as well-groomed and appropriately dressed for the appointment. She maintained good eye contact and demonstrated cooperative behaviour, appearing more relaxed than during initial testing sessions. Her speech was normal in rate and volume with clear articulation. Mary described her mood as “anxious but relieved to finally understand what’s happening” with affect congruent to her stated emotional state. Her thought processes were coherent and organised throughout the discussion. Mary was fully oriented and demonstrated good comprehension of the assessment findings, showing improved insight into her cognitive changes and their implications for daily functioning.
Summary of Assessment Findings Discussed
- The assessment findings were explained, with emphasis on Mary’s cognitive strengths in verbal reasoning and problem-solving alongside documented weaknesses in processing speed and memory functions.
- Diagnostic impression of Mild Neurocognitive Disorder due to Traumatic Brain Injury was discussed, with explanation that this represents a medical condition rather than personal failure.
- The brain injury analogy of “temporary roadworks” was used to explain how cognitive processes might be slowed but not permanently blocked.
- Test results were connected directly to Mary’s reported difficulties with work tasks and daily organisation, validating her subjective experiences.
Reaction and Understanding
- Mary expressed relief upon hearing the findings, stating “I thought I was going crazy or just being lazy.”
- She demonstrated good understanding of her cognitive profile and agreed with the assessment results.
- Mary asked thoughtful questions about prognosis and expressed concern about returning to work effectively.
Recommendations Discussed
- Cognitive rehabilitation referral was explained as skills training to develop compensatory strategies, with Mary expressing enthusiasm about this approach.
- Workplace accommodations were discussed, including graduated return to work and environmental modifications. Mary agreed to speak with her supervisor about implementing recommended accommodations.
- Sleep hygiene recommendations were provided with rationale about supporting brain recovery.
- Reassessment in six months was scheduled to monitor progress and adjust recommendations as needed.
- Action steps agreed upon include Mary contacting occupational therapy services within two weeks, scheduling meeting with workplace supervisor to discuss accommodations, implementing daily routine modifications, and maintaining regular neurologist follow-up.
- Mary will monitor her progress using provided tracking sheets and contact the clinic if concerns arise before scheduled reassessment.
Report Distribution
Written report will be sent to referring neurologist Dr. Novo Psych with Mary’s consent. Copy will be provided to Mary directly and to occupational therapy service upon referral. Confidentiality limits were reviewed, particularly regarding workplace disclosure of specific diagnostic information.
Additional Support Provided
- Psychoeducation about neuroplasticity and brain recovery was discussed to instill hope for continued improvement.
- Mary’s resilience and positive attitude were highlighted as important factors supporting her rehabilitation potential.
Follow-up Plans
- Check-in phone call scheduled for six weeks to assess progress with implementing recommendations.
- Formal reassessment appointment booked for six months to evaluate cognitive recovery and effectiveness of interventions.
- Mary was advised to contact the clinic if new symptoms emerge or if current difficulties worsen significantly.
Client’s Questions and Concerns
- Mary asked about expected timeline for cognitive recovery, driving safety, and impact on future career advancement.
- She expressed concern about disclosure of brain injury to her employer and wanted clarification about workplace rights.
- Questions about exercise and activity restrictions were addressed, with encouragement provided about maintaining normal activities as tolerated.
Session Summary
Mary responded very positively to the assessment feedback, expressing relief at having an explanation for her cognitive difficulties. Key recommendations around cognitive rehabilitation and workplace accommodations were well-received with clear action steps established. The session was productive with Mary demonstrating good understanding of her condition and strong motivation to implement recommended strategies.
- Template Type
- Session Note
- Note Dictation
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