Are line item questions regarding infant and child development necessary in a well-child note if a completed Ages and Stages Questionnaire (ASQ) is already included in the patient chart?

Documentation Requirements for Well-Child Developmental Assessment

If a completed Ages and Stages Questionnaire (ASQ) is already documented in the patient chart with results clearly marked as normal or abnormal by the EHR, you do not need to duplicate line-item developmental questions in your well-child note. The ASQ itself serves as the standardized developmental screening documentation required by current guidelines.

Rationale for This Approach

The American Academy of Pediatrics recommends surveillance at all well-child visits combined with screening for developmental delay at 9,18, and 30 (or 24) months using a standardized developmental screening tool 1. The key requirement is use of a validated screening tool, not documentation of individual developmental milestone questions 1.

What the ASQ Accomplishes

• The ASQ is a validated, parent-completed screening tool that examines communication, gross motor, fine motor, problem solving, and personal-social domains 1
• It has demonstrated sensitivity of 77-84% and specificity of 77-81% for detecting developmental delays 2
• The ASQ meets the accepted standards for developmental screening (sensitivity 70-80%, specificity approximately 80%) 1
• When properly completed and documented, it fulfills the standardized screening requirement 1

Essential Documentation Elements

Your well-child note must include the following to be complete 1:

• Confirmation that the ASQ was completed (which your EHR already does automatically)
• The ASQ results (normal/abnormal status, which your EHR documents)
• Your clinical surveillance observations - brief notation of any parental concerns, your observations of the child during the visit, and whether these align with or contradict the ASQ results 1
• Action taken - if abnormal, document referrals made; if normal but you have clinical concerns, document your plan 1

Why Additional Line Items Are Redundant

• Parent-completed tools like the ASQ are more time-efficient than directly administered tools and meet the same screening standards 1
• Studies show that 67.5% of ASQ-detected delays were not identified by pediatrician clinical impression alone, demonstrating that the standardized tool provides information beyond clinical questioning 3
• The ASQ has higher sensitivity (82%) and specificity (78%) compared to physician clinical judgment alone 4

Critical Caveats

You cannot rely solely on the ASQ without any clinical input 1. Your note should include:

• Brief surveillance statement: "Parent denies developmental concerns. Child observed to have age-appropriate social interaction, language, and motor skills during visit" or similar 1
• Reconciliation of discrepancies: If the ASQ is normal but you observe concerning behaviors, or vice versa, document this and your clinical decision-making 3, 4
• Context for high-risk children: For children with known risk factors (prematurity, chronic illness, previous delays), consider adding a brief statement about specific domains of concern even when ASQ is normal 1

When Additional Documentation IS Required

You must document additional developmental details when 1:

• The ASQ identifies delays (document specific domains affected and referrals made)
• You have clinical concerns despite normal ASQ (document specific observations and plan)
• The child has known developmental risk factors requiring enhanced surveillance 1
• There are parental concerns about development that warrant discussion beyond the ASQ 1

Common Pitfalls to Avoid

• Do not ignore discrepancies between ASQ results and your clinical observations - document your reasoning for the final assessment 3, 4
• Do not assume the ASQ alone is sufficient without any clinical surveillance statement 1
• Do not fail to document follow-up plans when screening is abnormal - referral rates should increase with standardized screening 3
• Do not use the ASQ as a diagnostic tool - abnormal results require comprehensive developmental evaluation for diagnosis 1