ASD under 5s

Pre-Clinic Information (not to be included in clinician proforma/output) Tabbed Journal: Information from ITC, if available. Detailed Family History/State if has a known social worker/on a CHIN Plan Pregnancy History/Early Developmental History until age 2.5 years (unlikely to be referred prior) Name of Educational Setting: Initial Pathway Selection (Subject to change/Please State in Words as well as Number) Referral Information: (Include Date of Referral and Source of Referral/any directly observed educational information can be mapped to ASD criteria by care navigators) State Level of Intervention for Learning (My Plan/EHCP) Scribe Involvement to commence here: (no patient identifiers/non-organisational email (Clinicians own professional responsibility/recommend NHS email) Not for use in with microphone in clinic situation/clinician aid for scribe/adminstrative structuring from clinic. Neurodevelopmental Medical Assessment for the Under 6s: Initial Appointment (for suspected global developmental delay and/or Autistic Spectrum Condition/Disorder Referral Information [include whether nursery/other initiated the referral and whether concerns shared by parents - do not include name of nursery ] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Voice of the Child [questions around educational setting, friends, play, toys, why the child thinks they are here; will provide evidence for Clinician Directly Observed Communication A1 and Nonverbal communication A2, Child report of Play and Relationships A3] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Parental Concerns (include up to 5 main concerns and also state motivation for pursuing assessment) [main headline issues followed by general consultation note. Could include motivations for pursuing assessment] 1. [first parental concern] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) 2. [second parental concern] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) 3. [third parental concern] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in brief bullet points.) General Consultation [Include reported social communication skills - map to ASD criteria as directly observed by clinician ] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Sensory Issues (evidence for B4) and Motor Mannerisms (parental report of B1) [include evidence for B1] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Birth History [include pregnancy, delivery, neonatal period, early sleep pattern and temperament, early feeding and weaning, first year] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Early Developmental History/Milestones [Motor: include minimum walking unaided, Fine Motor Skills, Speech and Language (e.g., babbling, age first words, age linking sentences, understanding simple requests), Early social skills (including smiling, early social interactions, pointing and gestures)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Developmental Update [compared to peers, additional support, and include any evidence of regression (RED FLAG)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Past Medical History, Medication, Allergies, Immunisations [only state confirmed diagnosis. If diagnosis of mood disorder, only include if diagnosed by the CAMHS team] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Vision and Hearing [include vision and hearing details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Family History/Composition [include as minimum family history of ASD/ADHD/Global Developmental Delay/Learning Disability/Specific Learning Difficulty) – refer to electronic record for confidentiality] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Sleep [include sleep details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. State if on melatonin and date of commencement if known). Diet [include diet details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Emotional and Behavioural (map to any ASD criteria: parental report) State of CAMHS involvement. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentence (ms.) Clinician Observations of child in clinic (map to any ASD criteria: Directly observed by clinician) [Any direct observations – multiple categories directly observed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Physical Examination [must include characteristic facial features/any skin markers and HC] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Weight: [include weight] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on the same line.) Height: [include height] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on the same line.) Head circumference: [include head circumference] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on the same line.) BMI: [include BMI] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on the same line.) Clinicians Impression [include what has been communicated to parents] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) …..and the child will remain/be placed on pathway Instructions for Next Steps Letter [specify who is responsible: Clinician, Care Navigator, Community Child Health Admin] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) For dictated clinic letter to follow, if required/requested (can include patient identifiable data when dictated on lexacom) Diagnosis List [only state confirmed diagnosis. For mood disorder, only include if diagnosed by the CAMHS team] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Other Issues [not formal diagnosis can include subjective behaviours of anxiety and low mood] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Medication List [include medication list] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Involved Professionals [include involved professionals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Attends [which educational setting] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Signed off [Name of doctor and Specific Job Role] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Addendum: Autism Pathway Assessment Criteria (Important to specify Parental Report or Directly Observed by Professional) Communication (A1): [include communication details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Non-verbal communication (A2): [include non-verbal communication details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Playing relationships (A3): [include playing relationships details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Repetitive behaviours (B1): [include repetitive behaviours details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Routine and preference for sameness (B2): [include routine and preference for sameness details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Patterns of interest (B3): [include patterns of interest details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Sensory differences (B4): [include sensory differences details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Overall impact: [include overall impact details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)