Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Evaluation of developmental delays
Follow-up visit for developmental progress monitoring
II. History of Present Illness:
Age of child
Concerns about developmental milestones (gross motor, fine motor, speech/language, social/emotional, cognitive)
Specific areas of developmental delay (if identified)
Age at which delays were first noticed
Progression of delays or any recent changes
III. Past Medical History:
Prenatal history (maternal infections, complications during pregnancy)
Birth history (prematurity, low birth weight, complications during delivery)
Medical history (genetic conditions, chronic illnesses, hospitalizations)
Family history of developmental delays or intellectual disability
IV. Social History:
Home environment (stimulating, supportive)
Socioeconomic status
Access to early intervention services (if any)
V. Developmental Assessment:
Use of standardized developmental screening tools (e.g., Ages & Stages Questionnaires (ASQ))
Formal developmental testing may be considered (depending on age and needs)
Observations of the child’s interaction with the environment and caregivers
VI. Physical Exam (consider as appropriate):
General physical exam (assess for any dysmorphic features)
Neurological exam (muscle tone, reflexes, coordination)
VII. Assessment:
Presence and severity of developmental delays in specific domains.
Possible underlying causes of developmental delay (genetic, neurological, environmental).
Consideration of differential diagnoses (e.g., autism spectrum disorder, intellectual disability).
VIII. Plan:
Based on the assessment, the plan may include:
Early intervention services: Referral to specialists (physical therapy, occupational therapy, speech therapy) for targeted interventions.
Medical evaluation: Addressing any underlying medical conditions that may be contributing to the delays.
Genetic testing: May be considered in some cases.
Social support services: Connecting families with support groups or other resources.
Follow-up appointments: Regular monitoring of developmental progress and adjusting the plan as needed.
IX. Prognosis:
Discuss the prognosis based on the severity of delays, identified cause (if any), and the child’s response to intervention.
Early intervention can significantly improve outcomes for children with developmental delays.
X. Notes:
Address the family’s concerns and provide emotional support.
Use clear and understandable language when explaining the diagnosis and plan.
Offer resources and referrals for further information and support.
XI. Resources:
Consider providing patient education materials on developmental delays from reputable sources (e.g., Centers for Disease Control and Prevention (CDC), National Institute of Child Health and Human Development (NICHD))