Cognitive Impairment Care Staff Communication Form

This form is designed for speech-language pathologists working in a long-term care or rehabilitation inpatient environment. SLPs can fill out the form in under two minutes and share with physician, nursing, social services, psychological, and therapy staff to ensure adequate understanding of individual cognitive impairments. The form includes quick scoring boxes for the MOCA, MMSE, SLUMS, and a blank area for other test results. It includes quick checkboxes to identify memory, orientation, and problem solving/sequencing abilities. It also contains room for individualized care notes.

Full access PDF is $8. Once purchased, you may save to your computer and print as many times as needed for your clinical practice.

MIX & MATCH, BUNDLE & SAVE: All Full-Access PDFs are discounted when you bundle:

• 1 for $8
• 2 for $12 ($6 each)
• 3 for $15 ($5 each)

Discount applied automatically at checkout.

If you purchase 20 color copies, 20 printed color copies will be delivered to your mailbox. Does not include access to PDF file.

Please note that PDFs are not easily opened, saved, or manipulated on phones or tablets. We recommend only downloading on a computer after purchase. Digital download links will be available after payment on the checkout page and in your order confirmation via email. You will have 5 download attempts over 1 month to access the file. Only the purchaser may access and use the file for their own clinical practice.

It is ok to:

• Share a printed copy of this resource with a patient/client, their family members and friends, and non-SLP/OT/PT related staff such as nursing, home healthcare providers, physicians, CNAs, social services, dietitians, activities teams, teachers, caregivers, etc.
• Digitally share the file via online, secure, HIPAA-compliant teletherapy software platforms to any of the people listed in the above point in the context of teletherapy.
  

It is not ok to:

• Share any digital copy with clients outside of the context of teletherapy.
• Store these files in any publicly accessible online storage system, such as a shared Google drive or other online storage service.
• To share these files with other SLP/OT/PT related colleagues or friends. Please refer, don’t share.

Tech specs: Digital download. 1 page. 8.5 x 11 inches. PDF format. 101 KB.