Developmental Screening Documentation (Standardized Tool)

Date of Screening: [Date (YYYY-MM-DD)] (If date entered differs, add: Date entered: [YYYY-MM-DD])

Setting: [standalone visit / well-child addendum / nurse visit workflow]

Reason for Screening: [routine age-based / triggered by surveillance concern / caregiver request / follow-up of prior borderline or positive screen] (Add brief context only if explicitly stated.)

Corrected Age: [Corrected age used for scoring] (Include only if prematurity correction was used; otherwise omit this line.)

Caregiver Present: [Name and relationship]

Interpreter Used: [yes / no] (If yes, include: Interpreter ID or language: [ID or language])

Instrument and Administration

(If the instrument was not completed, replace this entire section with: Instrument not completed — Reason: [reason]. Plan to complete: [plan and timeframe]. Then omit the Results and Interpretation sections.)

Instrument: [Instrument name] — [Version/edition] — [Age interval/form used]

Module(s): [Modules/components administered] (Include only if the tool has distinct modules; otherwise omit.)

Administration Method: [caregiver self-complete — paper / caregiver self-complete — electronic / staff-administered with standardized prompts]

Informant: [Name(s) and relationship(s)] (Identify primary respondent if multiple.)

Completeness: [complete / partially complete / invalid] (If incomplete, specify sections missing and whether scoring remains valid per instrument rules.)

Administered/Scored By: [Name and/or role]

Form Location: [EHR flowsheet / scanned media / patient portal / other location]

Limitations: [Factors affecting accuracy, e.g., language mismatch, literacy concerns, acute illness, caregiver unfamiliarity with child's typical skills] (Omit if none.)

Results

(Include only if the instrument was completed and scoring attempted. If not scored, replace with: Not scored — Reason: [reason]. Plan: [plan to obtain scores].)

• [Domain name]: Raw score: [score]; Category: [interpretive category per instrument]
• (Repeat for each domain assessed.)

Overall Screen Interpretation: [negative / borderline / positive / invalid / incomplete] (Use tool-aligned terminology.)

Caregiver Concerns (from instrument): [yes / no] (If yes, summarize briefly. Use direct quotes only when materially affecting clinical decisions.)

Areas Driving Concern: [Specific skill areas or item patterns prompting concern] (Include only if borderline or positive. Do not transcribe item-by-item.)

Barriers to Valid Interpretation: [What prevented valid interpretation; plan to obtain valid results] (Include only if results are incomplete or invalid. Do not label as negative when incomplete/invalid.)

Interpretation

(Required whenever a standardized screen was performed, even if the tool auto-calculated results. Omit only if the screen was not performed.)

[3–5 sentence clinician interpretation: Confirm that a validated developmental screen was completed and scored. State whether results are concerning and why. Note alignment with developmental surveillance and skills observed today. Acknowledge any limitations affecting reliability without dismissing the score without justification. Clarify that screening indicates risk requiring monitoring or further evaluation, not a diagnosis. Specify whether concerns are domain-specific or global. If urgent red flags such as regression are present, document escalation steps and time-sensitive actions.]

Caregiver Discussion

Results reviewed: [Summary of discussion of findings and their meaning]

Caregiver understanding/response: [Understanding, questions, preferences expressed]

Counseling provided: [Developmental promotion activities, coaching, resources] (Keep concise; do not duplicate anticipatory guidance documented elsewhere in well-child note.)

Referral education: [Benefits of early intervention discussed, referral process explained, expected timelines] (Include only if referral recommended.)

Assessment and Plan

(Format as problem-oriented list. Select the pathway matching the overall interpretation. If screening was not performed, document reason and plan to complete here. Never infer a negative screen if required elements are missing.)

• Problem: Developmental screening — [Instrument and age interval] — Overall interpretation: [negative / borderline / positive / invalid / incomplete]
  • Assessment: [Concise assessment statement. For borderline/positive, identify specific domain(s) affected and functional relevance.]
  • Negative screen plan: Routine surveillance continues; next screening at [age/interval per health supervision schedule]. (Include only if negative.)
  • Borderline screen plan: (Include only if borderline.)
    • Domains borderline: [list]
    • Home activities/coaching: [brief plan or resources]
    • Rescreen in: [timeframe, e.g., 2–3 months]
    • Return sooner if concerns persist or worsen; consider referral if no improvement by rescreen.
  • Positive screen plan: (Include only if positive.)
    • At risk for: [developmental delay — domain(s) or global]
    • Referrals placed: [Service (e.g., Early Intervention/Part C, school-based evaluation if ≥3 years, Audiology, Speech, OT, PT, Developmental-Behavioral Pediatrics)] — Date placed: [date] — Priority: [routine / urgent] — Scheduling: [family to call / clinic to facilitate] — Follow-up to confirm connection: [timeframe]
    • Additional evaluations ordered: [list, or omit if none]
    • Safety-net guidance: Contact clinic sooner for [specific red flags or worsening signs]
    • Follow-up appointment: [timeframe] to confirm referral linkage and reassess
  • Incomplete/invalid plan: Not interpretable due to [reason]. Plan to obtain valid results: [method and timeframe]. (Include only if incomplete/invalid.)
  • Referral declined/deferred: Shared decision-making documented. Reason: [reason]. Follow-up plan: [monitoring steps, rescreen date, return precautions]. (Include only if applicable.)