Behavioral Rating Scale Scoring Note

Date of Documentation: [Date]

Date of Instrument Completion: [Date(s) completed] (If completion date is unknown, state "completion date unknown" and document best available anchor such as portal receipt date.)

Author/Credentials: [Author name, degree(s), license]

Administered by: [Name/role or self-administered method]

Interpreted by: [Name/credentials] (If same as author, state "same as above.")

Linked Encounter: [Encounter linkage or context]

Reason for Assessment: [screening / diagnostic evaluation / baseline severity / treatment monitoring / school or IEP support / medication response monitoring]

Instruments Administered

(List all instruments completed. Note any instruments started but not completed or invalid due to missing items or response validity concerns.)

• [Instrument name (acronym)] — [Version/form] — [Informant name and relationship] — [Reference timeframe] — [Administration mode] — [Language if not English] (If incomplete or invalid, state reason.)
• [Additional instruments as applicable]

Instrument Results

(Create a separate block for each instrument-informant combination. Do not state diagnostic conclusions in this section.)

[Instrument name (acronym)] — [Version/form] — [Informant name and relationship/role]

Administration context: [Date completed]; [Date reviewed]; [Medication status during rating period if clinically relevant]

• Completeness: [All items answered / Missing items: number and item IDs] (Apply instrument-specified prorating only if permitted by manual; otherwise mark results as invalid/incomplete.)
• Raw/scale scores: [Total score]; [Subscale scores by domain as applicable]
• Norm-referenced scores: [Percentile and/or T-score] — [Norm group used] (Include only if normed scores are used.)
• Symptom counts/thresholds: [Symptom counts]; [Impairment indicators]; [Cutoff applied]; [Result relative to cutoff]; [Severity category if defined]
• Concerning item flags: [Items indicating self-harm, harm to others, or other high-risk responses] (Explicitly list; do not bury within totals. State "none" if no concerning items endorsed.)

Brief interpretation: [1–3 sentence synthesis stating which domains are elevated and typical clinical implications; note within-instrument patterns, impairment present vs absent, and key limitations such as single informant, incomplete items, or setting-limited observation. Do not state diagnoses.]

(Repeat block above for each additional instrument-informant combination.)

Cross-Informant Comparison

(Include this section only if two or more informants or settings are represented. Omit entirely for single-informant assessments.)

[Summary of concordance/discordance across informants and settings]; [Clinically meaningful discrepancies]; [Plausible explanations such as differing structure demands or observer access]; [Additional collateral needed: yes/no; specify sources and whether releases are required]

Clinical Interpretation

[Clinical context for why assessment was administered now]; [Integrated synthesis of whether results support or do not support working diagnoses]; [Severity level]; [Functional impact]; [Statement that rating scales are adjunctive tools requiring clinical correlation and are not diagnostic alone]

• Multi-setting documentation: [Whether symptoms and impairment are present in more than one setting and sources supporting this] (Include for ADHD evaluations.)
• Comorbidity flags: [Anxiety, depression, or behavioral concerns warranting further assessment] (Include if indicated by scales.)
• Treatment monitoring trends: [Prior score(s) with date(s)]; [Trend: improved / stable / worsened]; [Whether response criteria are met per clinical plan] (Include for monitoring visits.)
• Limitations: [Sampling, informant, completeness, timing relative to clinical events or medication changes]

Safety Follow-up

(Required section if any instrument response suggests suicidal ideation, self-harm, severe depressive symptoms, aggression, violent ideation, or other safety concerns. Omit only if no concerning items were endorsed.)

• Trigger: [Specific item, response, and instrument that prompted follow-up]
• Same-day risk assessment: [Ideation]; [Plan]; [Intent]; [Recent/past behavior]; [Access to means]; [Protective factors]
• Overall risk level: [low / moderate / high / imminent] — [Brief rationale]
• Mitigation plan: [Safety plan elements]; [Crisis resources provided]; [Means restriction counseling]; [Supervision recommendations]; [Follow-up timeframe]
• Disposition: [Outpatient / urgent follow-up / ED evaluation / higher level of care] — [Rationale]
• Outreach attempts: [Methods, times, outcomes, and escalation steps] (Include if patient could not be reached.)

Care Plan

• Medication: [Initiation / adjustment / continuation]; [Name, dose, frequency]; [Rationale tied to results]
• Therapy/behavioral interventions: [Type and focus]; [Goals informed by scale results]
• School supports: [504/IEP documentation, classroom strategies, school communication] (Include if applicable.)
• Referrals: [Specialty and reason for referral] (Include if indicated.)
• Further diagnostic workup: [Additional assessments if indicated]
• Results review: [Document that results were reviewed with patient/caregiver, meaning explained, and questions addressed]
• Follow-up: [Interval and modality]
• Next measurement plan: [Instrument(s) to repeat]; [Who will complete]; [Timing and clinical rationale]

Documentation

• Original instrument location: [Scanned document / flowsheet / portal questionnaire / third-party platform]
• Scoring method: [Manual calculation / EHR auto-score / third-party platform]; [Clinician verified accuracy: yes / no]
• Version control: [Specify which version was used if multiple submissions exist]