Developmental Screening Interpretation Note

Date: [Encounter date]

Patient: [Patient name]

Age at Screening: [Chronological age] (Include corrected age and whether correction was used for scoring, if applicable)

Location: [Clinic / telehealth / school-based / home / other]

Screening Context

[Indication for screening, language/interpreter use, validity factors] (1–3 sentences. State whether screening is routine age-based per AAP schedule or triggered by specific concern from parent, clinician, or school. Note language used and interpreter involvement if relevant. Include factors affecting validity such as hearing/vision impairment, setting of completion, or literacy barriers. If indication is unknown, state "Indication not documented" rather than inferring.)

Screening Instrument(s)

(Repeat the following block for each instrument administered. Do not mix results or plans across different tools.)

[Instrument name]

Instrument: [Exact name and version/revision]

Domain: [General development / Autism / Social-emotional / Other]

Language Version: [Language of form]

Mode: [Paper / tablet / patient portal / interview-administered]

Date Completed: [Date if different from encounter date]

Informant: [Name and relationship to child] (If not parent/caregiver, briefly note reason. If unknown, state "informant not recorded.")

Administered/Scored By: [Staff role or automated scoring]

Completeness: [Complete / partially complete / invalid] (If incomplete or invalid, note reason.)

Results: [Total score and interpretive category] (Include domain/subscale scores when they have separate thresholds and drive clinical actions. For two-stage tools, document Stage 1 result, Stage 2 result if performed, and final classification. Note whether result is borderline versus clearly abnormal when relevant. If results are pending, document method and timeframe for family contact.)

(Do not copy questionnaire items into the note. Store completed form as attachment or flowsheet per local policy.)

Clinical Interpretation

[Interpretation per instrument] (1–4 sentences per instrument. State what the screen suggests in terms of risk or concern level without assigning a diagnosis. Correlate with parent/clinician concerns—note whether results align or diverge. Document any limitations affecting validity. Interpret per the published scoring algorithm; do not infer diagnoses from screening alone. When multiple instruments were administered, clearly label each interpretation.)

Communication & Counseling

(Include only if results were discussed with family. Omit entirely if discussion has not yet occurred—instead document contact plan in Plan section.)

• [With whom discussed, relationship to child, interpreter use if applicable]
• [Key counseling points: screening versus diagnosis distinction, developmental promotion strategies, referral options and expectations]
• [Direct quote] (Only for high-stakes statements such as documented refusal)

Plan

• Referrals placed: [Destination and purpose] (e.g., Early Intervention/Part C, school-based evaluation, developmental-behavioral pediatrics, speech-language therapy, audiology)
• Referral status: [Placed today / information provided / already in process / family declined / deferred] (Include reason if declined or deferred)
• Services or resources provided: [Handouts, parent coaching resources, community navigation]
• Follow-up: [Timeframe, modality, whether re-screening planned]
• Safety-net instructions: [What should prompt earlier contact]

(For a normal screen with no concerns, Plan may be as brief as: "Continue routine developmental surveillance; re-screen per AAP schedule or sooner if concerns arise.")

Tracking

(Include only when referrals or follow-up tasks are needed. Omit if screen is normal with no follow-up actions.)

• Responsible person/role: [Staff role or care coordinator]
• Items to track: [Referral scheduled / evaluation results received / services started]
• Planned touchpoint date: [Date or timeframe]

(Generation guidance: Scale detail to clinical situation. Normal screen with no concerns: keep compact with brief context, instrument details, one-sentence interpretation, and minimal plan. Positive or borderline screen: include fuller interpretation, explicit referral documentation, and Tracking section. Negative screen with persistent parent/clinician concern: document the concern, note limitations, and include early follow-up or repeat screening plan. Incomplete or invalid screen: document reason, what was done or planned for repeat, and interim plan if concerns exist. Never imply counseling occurred or referrals were placed unless explicitly documented.)