Autism Screening Documentation (Standardized Tool)

Date: [Encounter date]
Patient Age: [Age in months]
Encounter Type: [18-month WCC / 24-month WCC / concern-based visit]
Informant: [Parent/caregiver name and relationship]
Language/Interpreter: [Language of administration; interpreter used if applicable]
Screening Indication: [routine age-based screening / high-risk status / parent concern / clinician concern / follow-up to prior screen] (If unclear for 18- or 24-month WCC, default to routine age-based screening.)

Screening Tool & Administration

Tool: [Tool name and version, e.g., "M-CHAT-R/F"]
Administration format: [paper / tablet / patient portal]
Completed by: [caregiver alone / staff-assisted / clinician-administered]
Follow-up interview component: [not indicated / completed same-day / pending]
Completeness: [complete / incomplete] (If incomplete, state reason and plan to complete.)

Pre-Screen Context

(Include only when relevant concerns or risk factors inform interpretation. Omit entirely for routine screens with no concerns.)

• Caregiver concerns: [Brief description or concise quotes relevant to social communication/behavior]
• Clinician surveillance observations: [Joint attention, pointing, social reciprocity, regression, repetitive behaviors, other relevant observations]
• Known risk factors: [Family history, prematurity, prior delays]
• Prior screening results: [Tool, date, and result]

Screening Results

Tool score: [Numeric score as defined by tool]
Risk category: [low / moderate / high likelihood]
Screen outcome: [positive / negative] (Do not state final result if screening incomplete or follow-up interview pending.)

Key domains of concern: [social communication / joint attention / play / sensory-repetitive] (Optional; summarize themes rather than listing individual items.)

Follow-up interview: [completed / deferred / not indicated]

• (If completed) Items remaining positive after clarification: [number]; Two-stage screen result: [POSITIVE / NEGATIVE]
• (If deferred) Reason: [reason]; Risk of delay discussed: [yes / no]; Planned completion: [date or timeframe]

Clinical Impression

[Brief synthesis integrating screening results, caregiver concerns, and clinician observations] (3–5 sentences. Explicitly state this is a screening result and not a diagnosis. Document current level of concern for ASD or other developmental delay. If screen-positive, note clinical urgency.)

Counseling & Discussion

Participants counseled: [Names and relationships]
Topics covered: [Meaning of results, screening versus diagnosis, value of early intervention, next steps, anticipated timelines]
Caregiver understanding/response: [Understanding acknowledged, questions addressed, concerns or preferences noted]
Resources provided: [Written materials, early intervention contact, evaluation clinic details]

Plan

(Include applicable items based on screening outcome.)

If screen-positive or concerns persist:

• Early Intervention/Part C referral: [Placed / pending; destination]
• Diagnostic evaluation referral: [Developmental-behavioral pediatrics / psychology / autism specialty clinic; status]
• Audiology referral: [Placed / not indicated] (Include if speech-language concerns present.)
• Follow-up to confirm referrals: [Timeframe and responsible party]

If screen-negative: [Routine surveillance continues; rescreen at [age/visit]] (Document enhanced surveillance plan if concerns persist despite negative result.)

If screening incomplete or follow-up pending: [Status and plan to complete by date]