213 lines
5.7 KiB
Markdown
213 lines
5.7 KiB
Markdown
# Developmental Screening Summary Form
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| Form ID | FRM-SCR-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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## Section 1: Child Information
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| Field | Entry |
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|-------|-------|
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| Child Name | |
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| Date of Birth | |
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| Age at Screening | |
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| Medical Record Number | |
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| Screening Date | |
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| Screened By | |
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## Section 2: Parent/Guardian Information
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| Field | Entry |
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|-------|-------|
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| Parent/Guardian Name | |
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| Relationship to Child | |
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| Contact Phone | |
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| Email | |
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## Section 3: Screening Tool(s) Administered
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### Primary Screening Tool
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- [ ] ASQ-3 (Ages & Stages Questionnaires, 3rd Edition)
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- [ ] M-CHAT-R/F (Modified Checklist for Autism in Toddlers, Revised with Follow-Up)
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- [ ] PEDS (Parents' Evaluation of Developmental Status)
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- [ ] SWYC (Survey of Wellbeing of Young Children)
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- [ ] BRIGANCE Early Childhood Screens
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- [ ] Other: _______________
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### Screening Tool Version/Age Range
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| Tool | Version | Age Range |
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|------|---------|-----------|
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| | | |
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## Section 4: ASQ-3 Results (if applicable)
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| Domain | Raw Score | Cutoff Score | Status |
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|--------|-----------|--------------|--------|
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| Communication | | | ☐ Above ☐ Monitoring ☐ Referral |
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| Gross Motor | | | ☐ Above ☐ Monitoring ☐ Referral |
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| Fine Motor | | | ☐ Above ☐ Monitoring ☐ Referral |
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| Problem Solving | | | ☐ Above ☐ Monitoring ☐ Referral |
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| Personal-Social | | | ☐ Above ☐ Monitoring ☐ Referral |
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### Overall Concerns Section Results
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- [ ] No concerns indicated
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- [ ] Concerns noted: _______________
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## Section 5: M-CHAT-R/F Results (if applicable)
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### M-CHAT-R Initial Screening
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- Total Risk Items: _____ / 20
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- Critical Items: _____ / 6
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### Initial Risk Level
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- [ ] Low Risk (0-2 total)
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- [ ] Medium Risk (3-7 total)
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- [ ] High Risk (8-20 total)
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### Follow-Up Interview Conducted
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- [ ] Yes
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- [ ] No (not indicated)
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- [ ] Declined by family
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### Follow-Up Results (if conducted)
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- Final Score after Follow-Up: _____
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- [ ] Passed screening
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- [ ] Failed screening - referral recommended
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## Section 6: PEDS Results (if applicable)
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### Concerns Identified
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- [ ] No concerns
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- [ ] Predictive concerns (Path A)
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- [ ] Non-predictive concerns (Path B)
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- [ ] Low concerns (Path C)
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- [ ] No concerns but parent comment/question (Path D)
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- [ ] No concerns, no questions (Path E)
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### Recommended Path
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- [ ] Path A: Refer for diagnostic assessment
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- [ ] Path B: Screen further with developmental screening tool
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- [ ] Path C: Age-appropriate anticipatory guidance
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- [ ] Path D: Address specific question/concern
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- [ ] Path E: Continue routine surveillance
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## Section 7: Developmental Domains Assessed
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| Domain | Status | Notes |
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|--------|--------|-------|
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| Expressive Language | ☐ Typical ☐ Concern ☐ Delay | |
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| Receptive Language | ☐ Typical ☐ Concern ☐ Delay | |
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| Gross Motor | ☐ Typical ☐ Concern ☐ Delay | |
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| Fine Motor | ☐ Typical ☐ Concern ☐ Delay | |
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| Social-Emotional | ☐ Typical ☐ Concern ☐ Delay | |
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| Cognitive | ☐ Typical ☐ Concern ☐ Delay | |
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| Adaptive/Self-Help | ☐ Typical ☐ Concern ☐ Delay | |
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## Section 8: Red Flags Observed
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### Autism-Specific Red Flags
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- [ ] Limited eye contact
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- [ ] No response to name
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- [ ] Limited or no pointing
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- [ ] Limited social smiling
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- [ ] Unusual sensory interests
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- [ ] Repetitive behaviors
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- [ ] Other: _______________
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### General Developmental Red Flags
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- [ ] Loss of previously acquired skills
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- [ ] Significant delay in milestones
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- [ ] Concerns about hearing or vision
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- [ ] Asymmetric movements
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- [ ] Parental intuition of concern
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- [ ] Other: _______________
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## Section 9: Risk Factors
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- [ ] Prematurity (<37 weeks gestation: _____ weeks)
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- [ ] Low birth weight (<2500g: _____ g)
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- [ ] NICU admission
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- [ ] Family history of developmental disorders
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- [ ] Environmental risk factors (poverty, exposure)
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- [ ] Medical conditions affecting development
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- [ ] Other: _______________
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## Section 10: Overall Screening Result
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### Summary Result
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- [ ] Passed - Development appears typical
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- [ ] Monitoring - Some concerns, rescreening recommended
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- [ ] Failed - Referral for comprehensive evaluation recommended
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### Domains of Concern (if any)
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## Section 11: Recommendations and Referrals
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### Immediate Actions
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- [ ] Routine developmental surveillance at next well-child visit
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- [ ] Rescreening in _____ months
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- [ ] Referral for comprehensive developmental evaluation
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- [ ] Referral to Early Intervention (Part C Birth-to-Three)
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- [ ] Referral to Preschool Special Education (Part B)
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- [ ] Referral to specific services:
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- [ ] Speech-Language Therapy
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- [ ] Occupational Therapy
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- [ ] Physical Therapy
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- [ ] Audiology
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- [ ] Ophthalmology
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- [ ] Other: _______________
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### Referrals Made
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| Service/Provider | Referral Date | Contact Information |
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|-----------------|---------------|---------------------|
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### Parent Education Provided
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- [ ] Age-appropriate developmental milestones discussed
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- [ ] Activities to promote development reviewed
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- [ ] Resources provided (handouts, websites, community programs)
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- [ ] Follow-up plan explained
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## Section 12: Parent Communication
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### Discussion with Parent/Guardian
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- Screening results explained: ☐ Yes
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- Questions answered: ☐ Yes
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- Recommendations discussed: ☐ Yes
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- Written summary provided: ☐ Yes
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### Parent Response
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- [ ] Agrees with recommendations
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- [ ] Has questions (documented below)
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- [ ] Declines recommendations
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- [ ] Requests additional information
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### Notes
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## Section 13: Follow-Up Plan
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| Follow-Up Action | Responsible Person | Target Date |
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|------------------|-------------------|-------------|
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## Section 14: Signatures
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| Screener Signature | | Date | |
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| Reviewed By (Provider) | | Date | |
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| Parent Acknowledgment | | Date | |
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*Form FRM-SCR-001 Rev 1.0*
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