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Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professio
CPT4 code
Neurobehavioral Status Exam
Name of the Procedure:
- Common Name(s): Neurobehavioral Status Exam
- Technical Term(s): Clinical assessment of thinking, reasoning, and judgment
Summary
A neurobehavioral status exam is a comprehensive evaluation performed by a healthcare professional to assess a patient's cognitive functions, including acquired knowledge, attention, language, memory, planning, problem-solving, and visual-spatial abilities. This exam helps identify any cognitive impairments or decline.
Purpose
- Medical Condition: Cognitive impairment due to conditions such as dementia, traumatic brain injury, stroke, or psychiatric disorders.
- Goals: To diagnose and document cognitive strengths and weaknesses, guide treatment planning, and monitor changes over time.
Indications
- Symptoms such as memory loss, confusion, difficulty concentrating, language difficulties, or changes in behavior.
- Patients who have experienced brain injuries, strokes, or who are suspected of having neurodegenerative conditions like Alzheimer's disease.
Preparation
- Patients should bring a list of current medications.
- No specific physical preparation like fasting is required.
- Preliminary diagnostic tests such as brain imaging may be recommended.
Procedure Description
- Interview: The healthcare professional gathers a detailed patient history and reviews any symptoms.
- Assessments: A series of standardized tests and questionnaires are administered to evaluate different cognitive functions:
- Attention: Tasks that measure the ability to focus and sustain attention.
- Memory: Tests involving recall of words, stories, or visual information.
- Language: Evaluations of naming, comprehension, and verbal fluency.
- Executive Functioning: Problem-solving tasks and planning exercises.
- Visual-Spatial Abilities: Tests that assess how well the patient understands visual and spatial relationships.
- Observation: The examiner observes the patient's behavior and interaction during the assessment.
- Tools: Pen and paper, computerized tests, and structured interview forms.
- Anesthesia/Sedation: Not applicable.
Duration
The procedure typically takes 1-3 hours, depending on the extent of testing required.
Setting
- The exam is usually conducted in a hospital, outpatient clinic, or specialized neuropsychology office.
Personnel
- The exam is administered by a physician, neuropsychologist, or other qualified healthcare professionals with training in neurobehavioral assessment.
Risks and Complications
- Common Risks: Minimal, with no physical risks involved.
- Rare Risks: Psychological distress if the patient becomes anxious or upset during testing.
Benefits
- Expected Benefits: Accurate diagnosis of cognitive impairments, aiding in the design of effective treatment and management plans.
- Timeframe: Results and recommendations are typically available within a few days to a week after the exam.
Recovery
- Post-Procedure Care: Not applicable as no physical recovery is needed.
- Follow-up: Follow-up appointments may be scheduled for discussing results and planning further treatment.
Alternatives
- Other cognitive assessment tools or scales.
- Pros and Cons: While other tools may be quicker or less comprehensive, the neurobehavioral status exam provides a detailed and thorough evaluation.
Patient Experience
- During the Procedure: The patient may feel a range of emotions, from curiosity to frustration, depending on the difficulty of the tasks.
- After the Procedure: Patients may feel tired due to the mental effort but no physical pain. Comfort measures, including breaks during the exam, are typically provided.