A developmental screening note records how a young child is developing: the family’s concerns, milestones in each area, the screening tool’s result, and what happens next. Copy the free template, see an 18-month autism screen and a 9-month preterm example, and check what each part needs.
Blank developmental screening template
FreeDEVELOPMENTAL SCREENING Child: [Name] Date of screening: [Date] Visit: [Well-child visit, scheduled screen, or visit for a concern] Clinician: [Name, credentials] CHILD AND AGE Date of birth and age: [Date; chronological age in months and days] Gestational age at birth: [Weeks; term or preterm] Corrected age: [Chronological age minus the weeks born early, for a child born preterm and under age 2; or not needed] Informant: [Caregiver and relationship, language used, interpreter if any] SURVEILLANCE Family's concerns: [Worries about movement, speech, play, behavior, or learning, in the caregiver's words; or none] Earlier development: [Past milestones, past screens and results, services already in place] Risk factors: [Preterm birth, NICU stay, a sibling or relative with autism or delay, hearing problems, exposures, family stress] Loss of skills: [Any words, social, or motor skills lost, and when; or none] MILESTONES BY DOMAIN Gross motor: [Skills seen and reported] Fine motor: [Skills seen and reported] Language and communication: [Sounds or words, understanding, gestures and pointing, response to name] Problem solving: [How the child explores and plays with objects; pretend play] Personal-social: [Eye contact, shared enjoyment, imitation, self-help] Seen in clinic: [What you observed yourself during the visit] STANDARDIZED SCREENING General screen: [Tool and age form, such as ASQ-3 or PEDS; who completed it; scores by domain against the cutoffs] Autism screen: [Tool such as M-CHAT-R/F; total score and risk band; Follow-Up Interview score; or not due] Other screens: [Social-emotional, language, or other tools, with results; or none] HEARING AND VISION Hearing: [Newborn screen result, risk factors, audiology since, response to sound today] Vision: [Red reflex, fixing and following, eye alignment, or instrument-based screen] EXAMINATION Growth: [Weight, length or height, head circumference with percentile and trend; plotted for corrected age if preterm] Neurological: [Tone, strength, symmetry, reflexes, gait] Other findings: [Skin findings, dysmorphic features, or other relevant signs; or none] RESULT Overall: [On track, monitor with an earlier rescreen, or refer] Reasons: [The screen results, surveillance, and risk factors behind the decision] Red flags: [Any found, with detail; or none] PLAN Rescreen: [Tool, age form, and date] Referrals: [Early intervention, audiology, speech-language pathology, developmental pediatrics, or other; date sent] Consent to share: [What the family agreed can be sent, and to whom] Explained to the family: [What the result means, what happens next, ideas for home, their questions] Follow-up: [Next visit, and reasons to come back sooner] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Pediatric clinic, 18-month well visit, both parents present
18-month-old boy, born at 39 weeks; no age correction needed. Seen with his mother and father, who speak Spanish and English at home. His mother completed both questionnaires in Spanish in the waiting room.
Parents’ concern: “He only says three words, and he doesn’t always turn when we call him.” Says “mamá,” “agua,” and “uh-oh.” Takes his mother by the hand to what he wants instead of pointing. Lines up his toy cars and spins the wheels for long stretches. His daycare teacher says he mostly plays on his own. No loss of words or other skills. Walked at 12 months. His 9-month ASQ-3 was above the cutoffs in all areas. Risk factors: a first cousin with autism; 3 ear infections in the past year, the last 6 weeks ago.
Gross motor: walks well, runs, climbs onto the couch, squats to pick up a toy. Fine motor: scribbles, stacks 3 blocks, feeds himself with his fingers and a spoon. Language and communication: 3 words used consistently; no pointing to ask or to show; follows a one-step request only with a gesture; responds to his name some of the time. Problem solving: uses a shape sorter; no pretend play, such as feeding a doll or talking on a toy phone. Personal-social: hugs his parents and laughs when tickled; rarely brings toys to show them; does not wave bye-bye. Observed: spun the wheels of a toy car for most of the visit; did not look where I pointed; turned to his name on the third call; brief eye contact; smiled when his father tickled him.
ASQ-3, 18-month questionnaire: Communication 10 and Personal-social 20, both below the cutoffs; Gross motor 55, Fine motor 45, and Problem solving 40, above the cutoffs. M-CHAT-R/F: total score 6, medium risk. Follow-Up Interview done today with both parents: score 4, screen positive.
Hearing: passed the newborn screen in both ears. Ear drums normal today. Needs a formal hearing test because of the language delay and recent ear infections. Vision: red reflex present and equal; fixes and follows; corneal light reflex symmetric.
Weight 11 kg (24.3 lb), 50th percentile. Head circumference 48 cm (18.9 in), 70th percentile, following his curve. Tone and strength normal and symmetric; steady gait. No café-au-lait spots or other skin findings. No dysmorphic features.
Refer. Positive M-CHAT-R/F after the Follow-Up Interview; ASQ-3 communication and personal-social scores below the cutoffs; 3 words, no pointing, an inconsistent response to his name, and no pretend play; a first cousin with autism. Red flag: no pointing or other gestures at 18 months. No loss of skills.
Referrals sent today, with his parents’ consent to share the screening results: developmental pediatrics for an autism diagnostic evaluation; early intervention for an assessment now, including speech-language pathology, without waiting for the evaluation; audiology for a full hearing test. Explained that a positive screen means he needs a closer look, not that he has autism, and that early support helps whatever the result. His father asked whether speaking two languages caused the delay: explained that learning two languages does not cause language delay or autism, and to keep using both. Ideas for home: name what he is looking at, copy his sounds, and wait for him to take a turn. Clinic nurse to call in 2 weeks to confirm the referrals were received. Visit in 6 weeks with the hearing result. Come sooner if he loses any words or skills.
Family practice, 9-month well visit, with her mother
9-month-old girl, born at 32 weeks, 8 weeks before her due date. Corrected age 7 months, used for her milestones and to choose the screening form. History from her mother, who completed the questionnaire online before the visit.
Mother’s concern: “My sister’s baby is the same age and already crawling.” No other worries about her movement, sounds, or play. Risk factors: preterm birth; 4 weeks in the NICU for breathing support and tube feeding; head ultrasound in the NICU normal. Rolled both ways at about 6 months. No loss of skills. No earlier formal screen.
Gross motor: rolls both ways; sits alone for a few seconds, leaning forward on her hands; takes weight on her legs when held standing; not crawling yet. Fine motor: reaches with either hand, passes a toy from hand to hand, rakes small pieces of food toward her. Language and communication: babbles “ba-ba” and “da-da” without meaning; turns to her name; laughs and squeals. Problem solving: looks for a toy she drops; bangs and mouths toys. Personal-social: smiles at her reflection; knows familiar faces; starting to be wary of strangers. Observed: sat briefly on her own, passed a block between her hands, babbled, and turned to her mother’s voice.
ASQ-3, 8-month questionnaire, chosen for her corrected age: Communication 50, Gross motor 45, Fine motor 50, Problem solving 50, Personal-social 55; all above the cutoffs. Autism screen: not due at this age.
Hearing: passed the automated ABR screen in both ears before NICU discharge. Audiology review at 8 months because of the NICU stay: normal hearing in both ears. Vision: red reflex present and equal; fixes on a toy and follows it across the midline; corneal light reflex symmetric.
Weight, length, and head circumference plotted for corrected age, all following their curves; head circumference 42 cm (16.5 in), 45th percentile. Tone normal: no head lag when pulled to sit, no stiffness in the legs, hands open. Moves all four limbs equally. Reflexes symmetric.
On track for her corrected age. Not crawling yet is expected at 7 months corrected. No red flags; no loss of skills. No referral needed.
Rescreen: ASQ-3 at the 12-month visit on Feb 10, using the 10-month questionnaire for her corrected age. Keep correcting for her early birth until age 2. Explained to her mother that her daughter should be compared with babies born around her due date, that many babies crawl between 7 and 10 months, and that some skip crawling. Ideas for home: floor play on her tummy, with toys just out of reach. Call sooner if she can’t sit on her own by 9 months corrected age, uses one hand much more than the other, seems stiff or floppy, or loses a skill.
The age the milestones and the screening form are judged against. For a child born preterm, that is the corrected age.
Avoid: Choosing the questionnaire by chronological age for a baby born early. A 9-month-old born 8 weeks early is screened as a 7-month-old.
What the family has noticed, the child’s history, and the risks that raise your concern. It happens at every visit, with or without a formal tool.
Avoid: Skipping the question about lost skills. Loss of words or social skills at any age needs a referral, whatever the screen shows.
What the child does in each area, seen in the room or reported by the family, so a change shows at the next screen.
Avoid: “Milestones met.” Name the skills, and say which you saw and which the parent reported.
The validated tool, the age form, and the result, by name and score. Many guidelines set a general screen at 9, 18, and 24 or 30 months, and an autism screen at 18 and 24 months. Local schedules differ.
Avoid: Copying the questionnaire into the note. Record the tool, the scores, and the result, and keep the completed form where your organization stores it.
The checks that can explain a delay, or hide one.
Avoid: Relying on a passed newborn hearing screen when speech is late. Hearing loss can start later; any language delay needs a formal hearing test.
One clear result, the reasons for it, and what happens next, with dates.
Avoid: “Will monitor” after a failed screen. A score below the cutoff or a positive autism screen needs a referral, or a written reason for a short-interval rescreen.
Compared with babies born at term on the same day, a baby born 8 weeks early can look delayed when she isn’t. Use corrected age for milestones and to choose the form, usually until age 2.
Name the tool, the age form, and the score in each domain. A score close to the cutoff today is the one to watch at the next screen.
A medium-risk score of 3 to 7 needs the Follow-Up Interview before you decide; without it, many children screen positive who don’t need an evaluation. A score of 8 or more can go straight to referral.
Children can usually get early intervention for a delay, before any diagnosis. Send the early intervention and evaluation referrals on the same day.
A passed newborn screen doesn’t rule out hearing loss that starts later, or fluid after ear infections. Every child with a speech or language delay needs a formal hearing test.
A screen above the cutoffs doesn’t cancel a parent’s concern, a red flag, or a lost skill. Loss of words or social skills at any age means refer now.
Vero Scribe drafts the developmental screening note in your template from the visit, with the family’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The child’s age, and corrected age if born preterm; the family’s concerns and any lost skills; milestones in each domain; the screening tool, age form, and scores; hearing and vision; a focused exam; one clear result; and the plan, with referrals, a rescreen date, and what you told the family.
Many guidelines recommend surveillance at every well visit, a standardized screen at 9, 18, and 24 or 30 months, and autism screening at 18 and 24 months. Others advise a formal tool when surveillance raises a concern. Local schedules differ, so follow the one where you practice, and screen at any age when a parent or clinician is worried.
Surveillance happens at every visit: asking about concerns, taking the history, watching the child, and noting risk factors. Screening uses a validated tool, such as the ASQ-3 or M-CHAT-R/F, at set ages or when surveillance raises a concern. Neither makes a diagnosis; a positive screen leads to an evaluation.
Subtract the weeks the child was born early from their age since birth. A 9-month-old born at 32 weeks, 8 weeks early, has a corrected age of 7 months. Use it for milestones and to choose the screening form until age 2. The ASQ-3 corrects for children born 3 or more weeks early.
A total of 0 to 2 is low risk; a child screened before age 2 is screened again at 24 months. A total of 3 to 7 is medium risk: do the Follow-Up Interview, and a follow-up score of 2 or more is positive. A total of 8 or more is high risk: refer for a diagnostic evaluation and early intervention right away. It is validated for children aged 16 to 30 months.
Usually, yes. The well-child note covers the whole visit, and development is one section of it. Use this template when the screen needs more room, such as a positive result, a parent’s concern, or a baby born preterm, and summarize the result in the well-child note.
Yes. Copy it, or download it as a Word or text file. No account needed.
The sick-visit SOAP note for children, with caregiver history, hydration, and weight-based doses.
Growth, development, screening, vaccines, and safety guidance, with 12-month and 5-year examples.
The diagnostic report after an autism assessment: history, ADOS-2 and other results, DSM-5-TR criteria, support levels, and recommendations.
Well-baby visits from birth to 5, organized like the Rourke Baby Record, with a BC 2-month and an Ontario 18-month example.
The preventive visit from 6 to 17, organized like the Greig Health Record, with an Ontario and a BC example.
Well visits, screening notes, and family instructions, drafted for your review.
The diagnosis codes used most in pediatric visits.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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