Healthcare Cognition Scale

Healthcare Cognition Scale

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Assessment Instructions

The Healthcare Cognition Scale is an examiner-administered instrument used to assess fundamental domains of cognition including orientation, memory, attention, language, visuospatial ability, and executive function. Scoring must be recorded immediately after each task. Use standard prompts; record responses verbatim in the response fields. Scores recorded here will be entered into the patient's permanent medical record unless otherwise restricted by the patient.

Cognitive Items and Scoring

1. Orientation — Time (ask for current date: month, day, year): Response: Score (0-3):

2. Orientation — Place (current location): Response: Score (0-1):

3. Immediate Registration — Examiner states three unrelated words clearly. Patient repeats: Words repeated exactly: Score (0-3):

4. Attention / Calculation — Serial subtraction of 7s from 100 (or alternate digit span). Responses: Score (0-5):

5. Delayed Recall — Ask patient to recall the three words after a short delay: Recalled words: Score (0-3):

6. Language — Naming two common objects (e.g., watch, pen): Responses: Score (0-2):

7. Repetition — Repeat the sentence exactly as stated: Response: Score (0-1):

8. Comprehension — Follow a two-step command: Response: Score (0-1):

9. Visuospatial — Clock drawing or copy task: Examiner notes: Score (0-1):

10. Executive Function — Category fluency (name as many animals in 60 seconds): Number named: Score (0-3):

Interpretation guidance (informational only): higher total score indicates preserved cognitive function; lower scores may indicate impairment. Clinical interpretation requires correlation with clinical history and further neuropsychological evaluation as appropriate.

Date of Assessment:

Privacy, Use of Results, and Authorization

The information obtained during this assessment is protected health information and will be maintained in the patient medical record. Results will be used for clinical care, treatment planning, and may be disclosed to other health care providers involved in the patient's care as allowed by law. By signing below, the patient or legal guardian authorizes the examiner to record findings, to include results in the medical record, and to disclose assessment results to other treating providers as necessary for ongoing care.

The patient has the right to refuse testing or to discontinue assessment at any time. Refusal or withdrawal will be documented in the record. Assessment may have limitations and should not be the sole basis for major clinical decisions without further corroborative evaluation.

I acknowledge receipt of the practice's privacy notice and understand how my information will be used.

I authorize administration of the Healthcare Cognition Scale and the inclusion of results in my medical record.

Certification and Signature

I certify that the information I have provided is accurate to the best of my knowledge. I understand the purpose of this assessment, the uses of the results, and my rights regarding withdrawal of consent. I attest that I am the patient named above or the legal guardian authorized to sign on the patient's behalf.

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