Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Algorithm for Cognitive Screening in Stroke Clients

See the appendix of the Stroke Assessment Nursing BPG for the specified scales


  • Client needs to be alert to participate in the cognitive screen.
  • With changes in medical status and/or environment, a reassessment of the client’s cognition is warranted.

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The Stroke Canada Optimization of Rehabilitation by Evidence (SCORE) Project Team (February 2005). Post-stroke Evidence-based Recommendations for Upper Extremity, Lower Extremity and Risk Assessment of Pressure Ulcers, Dysphagia,Falls, Cognition and Depression. Toronto: SCORE.