In conducting a neuropsychological evaluation, it is essential that we review relevant documents that will help us to fully understand the individual’s situation and injuries. In that regard, the following documents are important for us to review, if they are available:
• School Records: At a minimum, the B.C. Permanent School Record or its equivalent. Individual report cards, results of testing, and relevant letters are also of use, if available.
• Work Records: Resumes, job performance evaluations, records of job training, etc. as available.
• Pre-injury Medical Records: Family physicians’ records, consultations from relevant health professionals (see below), and records from previous hospitalizations (see below).
• Military Records: If available.
• Ambulance Report(s)
• Hospital Records: If they are brief, please send all records. If lengthy, the following are especially important: Admitting and discharge notes; records of medications given in hospital; all consultation reports; nursing notes; ratings of Glasgow Coma Scale scores (often given on an observation or “neuro” sheet); results of Neuropsychology, Occupational Therapy, Speech Pathology, and Physiotherapy assessments; early blood work including blood alcohol levels; X-ray reports, especially CT or MRI scans; EEG results. Physiotherapy notes, lists of valuables and similar administrative documents, doctors’ orders, and lab tests (other than as above) are generally not relevant.
•Consultation Reports: All reports prepared by neurologists, neurosurgeons, psychiatrists, psychologists, neuropsychologists, and family physicians; family physicians’ notes; additional consultation reports from other physicians (e.g., orthopedic physicians) as they shed light on additional problems (e.g., pain) or address neuropsychological status. Physiotherapy notes, and notes from other doctors are generally not relevant unless the doctor is providing care or has lab results such as those discussed under hospital records above.
• Rehabilitation Reports: All reports of rehabilitation consultants, occupational therapists, psychotherapists, counselors, speech pathologists, and similar individuals are of relevance.
• Neuropsychological Reports: If previous neuropsychological evaluations have been conducted, it is important that we receive the raw test scores from those evaluations as well as any reports that might have been prepared.
We recognize that not all of these records are available in every case, especially at the time of our assessment. The fact that some records are still not available is not to be a reason to delay the assessment. In such cases, we will generally provide an addendum to the original report as records become available.
The above list is intended to create a set of documents that will allow us to conduct a comprehensive review of the case while at the same time avoiding the time and cost of us reviewing excessive irrelevant documents. If you have any specific questions regarding whether to supply various documents, please do not hesitate to call us.