Post-stroke neuropsychological assessment report: template and example

A post-stroke neuropsychological assessment report is the document in which the neuropsychologist describes, from interviews, tests and observation, what the stroke has changed in the patient's attention, memory, language, spatial perception and behaviour, and what this means for rehabilitation, work and driving.

Where the assessment fits in the stroke pathway

In the acute phase, teams often run a quick screen (the MoCA, for example). The in-depth neuropsychological assessment comes later, in rehabilitation or as an outpatient, once the patient can sustain a testing session and the question becomes practical: what can they go back to, and with what support?

The French national health authority (HAS) says so plainly in its 2022 guideline on rehabilitation in the chronic phase of stroke in adults: after a detailed cognitive assessment, patients should be offered rehabilitation, and whatever the intervention, the aim is change that matters for the patient's daily life. Your report is the basis for that rehabilitation, so it should name precise targets, not only deficits.

In a paper presented to the French National Academy of Medicine in 2022, S. Jacquin-Courtois argues that assessment and treatment should target three levels: impairment, activity and participation. We suggest using these three levels as the thread running through every domain of the report.

Think about your readers too. The same report may be read by the neurologist or rehabilitation physician, the GP, the occupational therapist, the speech and language therapist, the occupational health doctor, a disability assessor and the patient. Any sharing outside the care team needs the patient's consent.

This guide follows the French framework, where the article was first written. In the UK and Ireland, the rules on driving and on reports for employers differ, so adapt those sections to your national guidance.

Domains to assess after a stroke

• Attention and processing speed. Slowing, divided attention, fatigue over the session. Often the most disabling problem for work and driving.
• Executive functions. Planning, flexibility, inhibition, initiation. Highly structured tests underestimate them, so note what you see in open-ended tasks.
• Memory. Tell a true memory deficit apart from poor encoding caused by attention problems or an incomplete copy.
• Language. After left-hemisphere damage, aphasia is treated with the speech and language therapist; state whether test instructions were understood.
• Praxis and gnosis. Limb apraxia, visuoconstructional problems, visual recognition disorders.
• Unilateral spatial neglect. Common after right-hemisphere damage and easy to miss on a single paper test. Combine several tasks with observation in real situations.
• Anosognosia. Compare what the patient says with what relatives report; this is central to safety and engagement in rehabilitation.
• Social cognition and behaviour. Irritability, apathy, disinhibition, difficulty reading other people's emotions.
• Mood, anxiety and fatigue. They affect performance and return to work; flag them and refer where needed.

Tests: cite them properly

Cite each tool with its reference or publisher, the version used and the norms applied. Some verified points:

• MoCA (MoCA Test Inc.). Under the certification policy on its website, certification is optional for screening based on the total score and required for anyone interpreting sub-scores or domains. A normal MoCA does not rule out attention problems or neglect.
• FAB, Frontal Assessment Battery, called BREF in French (Dubois, Slachevsky, Litvan and Pillon, Neurology, 2000): six subtests, total out of 18.
• Trail Making Test (Reitan), parts A and B, with the norms you state.
• Rey Complex Figure (Rey, 1941; Osterrieth, 1944), copy and recall. The copy also tells you about neglect and planning.
• Bells Test (Gauthier, Dehaut and Joanette, 1989): 35 bells among distractors; record omissions by side and where the search starts.
• Neglect battery by Azouvi and colleagues (Restorative Neurology and Neuroscience, 2006), including the Catherine Bergego Scale. The authors found that behavioural assessment was more sensitive than any single test.
• GREFEX criteria for dysexecutive syndrome (Godefroy and colleagues, Annals of Neurology, 2010).

Turning a score into plain language

You calculate the scores, deviations from norms and percentiles. The report lists them in an appendix and translates them in the body. Three phrasings that work:

• "He took much longer than people of the same age and education."
• "Almost all errors are on the left half of the page."
• "This result is within the normal range, but the effort required and the fatigue at the end show reduced reserve."

Driving, work, disability: what you write and what is not your call

Driving

In France, an order of 28 March 2022 lists the medical conditions compatible or incompatible with a driving licence. In a ministerial answer to the Senate on 21 November 2024, the Interior Ministry states that strokes other than treated and monitored transient ischaemic attacks require a medical check by a doctor approved by the prefect. According to service-public.fr, this approved doctor cannot be the patient's own GP, and the outcome can be unfit, temporarily fit (6 months to 5 years) or fit with restrictions. A good practice guideline endorsed by the HAS in 2016 on driving after acquired brain injury refers to specialist multidisciplinary assessment including an on-road evaluation.

Your role is to describe the abilities relevant to driving (speed, divided attention, scanning to the left, impulsivity, awareness of difficulties) and to refer for a medical opinion. We advise against the words "fit" or "unfit", which belong to the licensing doctor, and suggest stating clearly that the patient should not drive until that opinion is given. In the UK and Ireland, follow the guidance of your national licensing authority.

Return to work

Describe the actual job (hours, travel, multitasking, screens, safety) and where things break down. With the patient's consent, we suggest sharing the report with the occupational health doctor and presenting adjustments as options to discuss (part-time return, breaks, tasks without driving).

Disability assessments

Disability bodies need concrete impact, not a list of tests. "Leaves the left side of his plate and bumps into door frames on the left" says more than a score.

Complete report template to copy

Header. Neuropsychologist's name, contact details, professional registration number. Patient: name, date of birth, handedness, education, occupation. Assessment date(s). Referrer.

1. Reason for referral. The referrer's question (for example: assessment before return to work, with information on driving for the physician).

2. Relevant medical history. Date and type of stroke, territory, side of lesion, known motor and visual deficits (hemianopia), medication that may affect alertness, ongoing therapies.

3. Complaints and history.

• Patient's complaint: in their words, what they think they can resume.
• Relatives' observations: concrete examples, with the patient's consent.
• Previous life: work, driving, hobbies, independence.

4. Behaviour during testing. Alertness, fatigue, understanding of instructions, gaze to the left or right, reactions to failure, mood.

5. Results by domain. For each domain: tests used, result in plain language, qualitative observation, impact on daily life.

• General cognition (screening)
• Attention and processing speed
• Executive functions
• Verbal and visual memory
• Language
• Praxis and visuoconstruction
• Visual gnosis
• Unilateral spatial neglect (paper tests, observation in real situations)
• Awareness of difficulties (patient and relative compared)
• Social cognition and behaviour
• Mood, anxiety, fatigue

6. Summary. Three to six sentences: cognitive profile, link with the lesion, preserved abilities, impact on activities and participation.

7. Recommendations.

• Rehabilitation: targets, professionals, suggested frequency.
• Daily life: aids and adjustments, advice for relatives.
• Driving: abilities observed, no driving until medical opinion, referral to the physician.
• Work: options to discuss with occupational health.
• Applications: disability support where relevant.
• Reassessment: proposed timing.

8. Feedback session. Date, who attended, patient's reaction, documents given.

Appendix. Raw and standardised scores as a list, norms and versions used.

Fictional completed example: right middle cerebral artery stroke, neglect, working adult

Entirely fictional case. The scores are made up for illustration; in a real assessment, the neuropsychologist calculates and interprets them against the norms they use.

Patient. Mr Julien R., 47, right-handed, two years of higher education, sales technician who drives every day for work. Referred by the rehabilitation physician eight months after a right middle cerebral artery ischaemic stroke. Left hemiparesis largely recovered; visual fields to be checked by the ophthalmologist.

Reason for referral. Assessment before return to work; the physician asks for information to guide the driving question.

Complaints. Mr R. says "everything is fine" and wants to drive again next month. His wife reports that he bumps into door frames on the left, leaves the left side of his plate and loses his temper more quickly.

Behaviour. Cooperative, quick, sometimes hasty. Starts his visual searches on the right. Clear fatigue after an hour of testing.

Results.

• Screening (MoCA): borderline score; points lost on drawing and alternation.
• Attention: TMT A and B much slower than people of the same age and education, two alternation errors on B, corrected after a reminder.
• Executive functions: FAB 14 out of 18, weak fluency and motor sequences; in an open task he acts before planning.
• Memory: verbal memory within normal limits; poor recall of the Rey Figure, linked to an incomplete copy.
• Language: no impairment; speech sometimes tangential.
• Neglect: Bells Test 22 out of 35, omissions mostly in the left columns, search starting on the right; Rey Figure copy missing several left-side elements. In real situations (meals, corridors), neglect is visible.
• Awareness: clear gap between his view and his wife's; he puts his errors down to tiredness.
• Mood and fatigue: irritability, adequate sleep, marked fatigue late in the day.

Summary. The assessment shows persistent left spatial neglect, slowing with impaired divided attention and impulsivity, with partial awareness of these difficulties. Verbal memory and language are preserved. These problems currently affect daily life and, at this stage of rehabilitation, do not allow a return to the job as it stands.

Recommendations.

• Neglect rehabilitation: for the chronic phase (from six months), the HAS recommends prism adaptation and Visual Scanning Training (grade C); attention training with Time Pressure Management (grade B).
• Occupational therapy to carry scanning strategies into everyday tasks.
• Driving: Mr R. does not drive until the medical opinion is given. This report goes to the rehabilitation physician, who will refer him for a multidisciplinary assessment and to the approved doctor.
• Work: with his consent, share with the occupational health doctor; options to discuss: phased return, desk-based tasks at first.
• Reassessment in six months.

Common mistakes

• Concluding from the screen alone. A borderline MoCA tells you nothing about neglect in daily life.
• Looking for neglect with a single test. Combine cancellation, copying and observation.
• Interpreting visual memory without checking the copy. An incomplete copy distorts recall.
• Writing "fit" or "unfit" to drive. That word belongs to the licensing doctor.
• Ignoring fatigue. Note the time and length of testing.
• Writing anosognosia as a criticism. Prefer "Mr R. has limited awareness of his difficulties on the left" to "Mr R. denies his problems".
• Giving scores without sentences. GPs and disability assessors need the impact.

Checklist before sending

• The referrer's question gets an explicit answer.
• Side of lesion, visual and motor deficits are stated.
• Each test is cited with version and norms.
• Each domain links result, observation and daily life.
• Neglect is explored with at least two tasks plus observation.
• Awareness is documented from both patient and relative.
• Driving is addressed without a fitness opinion, with medical referral.
• Recommendations are specific, dated and include reassessment.
• The patient has consented to each recipient.

Why Delta suits this assessment

You calculate your scores and draw your conclusions; Delta calculates no scores and makes no diagnosis. After the session you dictate your observations and results, and Delta drafts the report in your vocabulary and structure, learned from your existing reports, then keeps the patient's history so the six-month reassessment starts from what was written. Data stays in Europe, in France, on infrastructure certified for health data, and the patient's name is pseudonymised before the AI. Learn more in what is Delta and on our page for neuropsychologists.

Further reading: our cognitive remediation session note template, the aphasia assessment report template for the speech and language side, and all our clinical document templates.

Frequently asked questions

Sources

• HAS, Rehabilitation in the chronic phase of stroke in adults (June 2022, in French)
• HAS, endorsement of the guideline on driving after non-progressive acquired brain injury (January 2016, in French)
• Service-public.fr, Driving licence and medical check for health reasons (checked 24 February 2025, in French)
• French Senate, Interior Ministry answer on medical checks after stroke (21 November 2024, in French)
• MoCA Test Inc., Training and certification (accessed 5 November 2026)