Screening Implementation Worksheet
1. Who will ensure that copies of screens are available each day for parents to complete?
2. Who will ask whether parents can complete the forms on their own or need assistance?
3. Who will help parents who need assistance9
4. Who will collect screens from families?
5. Who will score screens9
6. Who will attach screens to the chart or otherwise make sure they are available to clinicians'?
7. Who will locate patient education materials and referral resources? Who will follow up if needed
   How will this person know when to follow up9 
8. Who will explain results to families?
9. Who will contact referral resources when a referral is needed? Who will locate referral resources
   when needed9

Screening implementation Worksheet Page 1 Reprinted from dbpeds.org on 11/1/2007 © All rights reserved
       

10. What will you do with the screening materials once they've been discussed with families?
11. If using electronic records or age-specific encounter forms, who will indicate and where, 
    the fact that screening has been completed? 
12. Who will bill/code for completion of screens and for positive/negative results?
13. What procedure and diagnosis codes will you use?
14. Who will explain to utilization review personnel your decision about CPT and DX codes0
15. Where will you keep supplies of screens and patient education materials'"?
16. Who will lead staff through your rationale for deploying validated screening in your practice and 
    otherwise inspire them about the value of screening'? 
17. How will you handle things if staff is unwilling'"? 
18. What is your time frame for accomplishing a smooth screening process'? from ARCD project of the 
    Commonwealth Fund. Permission to reproduce is granted.

Screening implementation Worksheet Paqe 2 PoLHinted from dbpcds otg on 11/1/2007