Behavioral Health Screening Documentation (Pediatric)

Encounter Context

Visit type: [preventive / problem-focused / follow-up / post-ED / telehealth]
Reason for screening: [routine / symptoms / parental concern / school concern / prior positive / medication monitoring]
Informant(s): [patient / parent / both / other] (If other, note relationship)
Confidential time: [yes / no] (If no, briefly note why)
Interpreter: [none / language used]

Pre-test conditions affecting validity: [Validity limitations] (Include only if present; document limitation and any alternative assessment used)

Standardized Screening Results

(Repeat the following block for each instrument administered. If an expected screening was not completed, document in the subsection below instead.)

Screenings Not Completed

(Include only if an expected screening was not completed)

• [Instrument name]: [reason not completed]

Clinical Correlation

(Include when any screen is positive/borderline, informant discrepancy exists, or clinical concern persists despite negative screens. Omit if all screens negative with no clinical concerns.)

[Primary concern and time course: onset, duration, progression, precipitating factors]

• Core symptoms: [mood/irritability, anxiety/worry, attention/hyperactivity, behavioral concerns, somatic complaints]
• Functional impact: [school performance/attendance, home/family, peers/social, sleep, appetite] (Required if considering diagnosis)
• Relevant context: [stressors, bullying, family changes, substance exposure if age-appropriate]
• Relevant history: [prior diagnoses, therapy/psychiatry, hospitalizations, current medications, family psychiatric history]

(Use brief direct quotes only for safety-critical statements or patient's own framing of distress)

Safety Assessment & Disposition

(Required when suicide/self-harm items are positive at any level, suicide risk screen is positive, or clinician concern exists for self-harm, suicidality, psychosis, mania, severe agitation, or threat to others. Omit only if no safety concerns and all suicide-related items negative.)

Immediate Actions

• Supervision during assessment: [continuous observation / caregiver present / clinic staff present]
• Notifications: [who notified and when]
• Leave status: [patient remained / not permitted to leave / permitted to leave] — [rationale]

Brief Suicide Safety Assessment (BSSA)

• Suicidal ideation: [presence, frequency, duration, triggers, controllability]
• Plan/intent: [plan presence, intent level, preparatory behaviors] (Document at high level without detailed method description)
• Past behavior: [prior attempts, aborted attempts, nonsuicidal self-injury history]
• Access to lethal means: [firearms, medications, other] — [counseling provided, caregiver restriction plan]
• Protective factors: [reasons for living, caregiver supervision, social supports, treatment engagement]
• Co-occurring risk factors: [intoxication, severe insomnia, agitation, psychosis, recent trauma]

Homicidal Ideation or Violence Risk

(Include only if present)

• Specific concerns: [nature of threats or targets]
• Access to weapons: [access details and restriction plan]
• Immediate actions taken: [notifications, safety measures, referrals]

Disposition Decision

(Select one and provide brief rationale)

• Imminent/acute risk: [Requires same-day emergency/crisis evaluation; patient not permitted to leave until evaluated] — [rationale]
• Non-acute positive: [Appropriate for outpatient management with safety plan, lethal means counseling, and rapid follow-up] — [rationale]
• Negative screen with persistent concern: [rationale and escalation actions if any]

Safety Plan Elements

(Include when managing outpatient)

• Warning signs/triggers: [identified signs]
• Coping strategies: [internal coping skills]
• Support contacts: [family/friends, school supports, provider contacts]
• Crisis resources provided: [988, local crisis line, ED/911 indications]
• Lethal means restriction: [plan and responsible person]
• Follow-up timeline: [specific date within days]

Incomplete BSSA

(Include only if BSSA could not be completed)

[Elements completed] — [Elements not completed and reason] — [Interim safety actions taken]

Assessment

[Clinical synthesis linking screening results, clinical correlation, and safety assessment into overall impression]

(List problems in order of severity/acuity)

(Screening scores are not diagnoses. If screen is positive but diagnosis not assigned, document clinical reasoning.)

Plan

(Organize by problem)

Safety-specific follow-up: [follow-up interval in days] — [crisis instructions provided] — [lethal means restriction plan reviewed with caregiver] (Include when safety risk identified)

Active monitoring plan: [what is being tracked, by whom, next contact date] (Include when treatment deferred)

Administrative Notes

(Optional; include if needed for billing documentation)

• Instruments administered: [names of tools]
• Scoring and review: [confirmation that scoring completed and results reviewed/discussed]
• Time documentation: [total time and activities] (Include only if time-based coding used)