The 4-5 year review form  is completed at around 4-5 years of age and is carried out by a health visitor.

RDS  > Child Health Systems Programme - 4-5 year review @ 65

https://www.isdscotland.org/Health-Topics/Child-Health/Child-Health-Programme/Child-Health-Systems-Programme-Pre-School.asp

The 4-5 year review form is completed at around 4-5 years of age and is carried out by a health visitor. This review started in April 2017 and is offered to all children (implementation of this review may vary across Scotland). Examples of information collected include: development (social, behavioural, communication, gross motor, vision, hearing), physical measurements (height and weight) and diagnoses / issues (Read coded). Identification data such as name, address, GP etc. are also checked and updated.

HDR UK

National Services Scotland

List of any issues likely to be relevant to the child’s ongoing health, development, or wellbeing.  Up to 4 issues can be recorded on any one form.  Extra forms can be used to record additional issues if required.  There is no upper limit to the number issues that can be recorded on the system.

Summary  List of issues

Issues / Issues Status / Read Coding.   Recall & Unscheduled reviews

Review carried out 
-on examination 
-by telephone 
-by review of notes

Read code relevant to each issue listed by the Health Visitor responsible for the child health review (see above)

Read code

Date of the previous review where the recall/follow-up was requested

Recall requested on

Reason why an unscheduled review form has been completed for the child 
1 (transfer into caseload) 2 (outwith age range for routine      contact) 
3	(change of HPI – Health Plan  
    Indicator – outwith routine contact) 
4	(referral outwith routine contact)

Reason for using this form

Duration of recall/ follow up appointment to be scheduled 
S (short) 
M (medium) 
L (long)

Appt

Reason for recall

Reason for recall as noted n the previous review form

Reason for Recall

Indicates the status of each listed issue 
0	(referred/assistance requested) 
1	(issue ongoing) 
2	(no longer has issue) 
3	(amend issue) 
4	(no information available) 
5	(issue/code incorrectly recorded) 
6	(discharged due to DNA – did           not attend)

Issue status

Recall/ follow up appointments are in addition to the national schedule of universally offered child health reviews and are only requested by Health Visitors when clinically necessary. 
The interval specified must be greater than 4 weeks to ensure adequate time is available for the results of the current review to be input into CHSP-PS and the recall appointment invitation issued. Note Recall to GP is only on the 6-8 Week & Recall Forms

Recall to  HV/GP in

Updated Health Plan Indicator recorded at the end of the child health review. See Health Plan Indicator variable above for full definition. 
C (core) 
A (additional) 
U (unknown)

Updated HPI

Health Plan Indicator / Support Needs Status / Parental Consent

Signature and name of the health professional(s) completing the CHSP-PS form

Signature Print name

Professional identification number of the health professional(s) completing the CHSP-PS form

ID No:

Health professional(s) directly involved in delivering the child health review 	Must complete one box with Y (yes)

Practitioners involved in review:

Child’s status on the Support Needs System 
0	(Not active on SNS) 
1	(Active – not yet notified to doctor) 
2	(Active – not yet assessed) 
3	(Active – being assessed) 
4	(Previously on SNS) 
8 (No planned assessment)

Support Needs Status

Any additional information the Health Visitor wishes to record

Summary comment

Summary indicator of the child’s overall need for ongoing support. 
An additional HPI indicates that the child (and/or their carer) requires sustained (>3 months) additional input from professional services to help the child attain their health or development potential.  Any services may be required such as additional Health Visitor support, parenting support, enhanced early learning and childcare, specialist medical input, etc. 
C (core) 
A (additional) 
U (unknown)

Health plan indicator

Location(s) where the child health review was delivered

Place of review:

Record of any validated developmental assessment questionnaires/ tools completed as part of the child health review 
01	PEDS (Parents’ evaluation of       developmental status) 
02	PEDS:DM (Parents’ evaluation       of developmental status:       developmental milestones) 03 ASQ 3 (Ages and stages       questionnaire version 3) 
05	SDQ (Strengths and difficulties       questionnaire) 
06	ASQ:SE (Ages and stages       questionnaire: social and       emotional version 2) 07 SSLM (Sure start language       measure) 
08 M-CHAT (Modified checklist for       autism in toddlers) 
10	Other (indicates a different       validated developmental       assessment questionnaire was       administered as part of the child       health review) 
11	None

Tools

Developmental / ASQ Scores / Tools

Occipito-frontal circumference in centimeters to one decimal place

Scoring of the developmental assessment undertaken as part of the child health review relating to the specific development domains

ASQ Score

Child’s length or height (depending on child’s age/form) in centimeters to one decimal place

Length / Height

Date on which growth measurements were taken

Date measured

Child’s weight in kilograms to two decimal places

Weight

Results of the developmental assessment undertaken as part of the child health review relating to the specific developmental domains 
C - Concern newly suspected means that the concern has been identified for the first time as a result of the assessment undertaken within the child health review. 
P - Concern/ disorder previously identified means that the child was known to have developmental delay or a specific developmental disorder prior to the child health review being undertaken.

Development 
-Speech, Language 
  & Communication 
-Problem Solving 
-Emotional/Behavioural 
-Gross Motor 
-Personal/Social 
-Vision 
-Fine Motor 
-Hearing

Is the child to be deferred to the following year for school entry

Deferred entry

Future Action

Record of specific actions the Health Visitor intends to take to support the child/family following the child health review. 
‘Provide’ indicates that the Health Visitor and/or associated skill mix team will directly provide the specified additional support (only relevant for some options). ‘Signposted to’ indicates that parents have been given details of specified local services and how to access them. 
‘Discuss with’ indicates that the Health Visitor will formally discuss the child/family with the specified service to inform future management plans. 
‘Request assistance from’ indicates that the Health Visitor will formally refer the child/family to the specified service, whilst retaining responsibility for oversight of the child’s wellbeing and outcomes as their GIRFEC named person. 
W ‘Refused’ indicates that the carer has been offered provision/ signposting/ discussion/ referral to the specified service but has refused this.

School Code

Does the child currently regularly (at least once a week) attend the specified form of childcare for any period?

Attends 
-Nursery 
-Playgroup 
-Registered childminder 
-Other childcare 
-None

CHI no

Demographic / Birth details

Carer(s) present with child at review.  Primary carer refers to the adult living (at least most of the time) with the child who provides most day to day care.

Carer present with child (At Review)

Is English the main language spoken in the child’s home?

Is English 1st language at home?

Health Visitor identification number for Health Visitor responsible for the child’s care

Health Visitor

Date Health Visitor first visit was completed

Date of visit / review / assessment

Child’s ethnicity as stated by their primary carer

Ethnicity

Name/address/ postcode

If any pre-printed demographic data is incorrect it should be updated in the Change of Details box 
Updated Health Visitor identification number for Health Visitor responsible for the child’s care

Change of

Is the child routinely exposed to more than one spoken language in their home and/or care environment?

Bilingual/multilingual

Has BCG been given?

During the child health review, has the child’s carer raised specific concerns about any of the areas listed?

Concerns raised by carer

Child eligible to receive BCG vaccination

At risk TB

Gender

Is the child currently (at the time of the review) looked after by the Local Authority for any reason?

Current LAC status

Start of scheduling period the child health review was scheduled to take place

Scheduled date of review

Was the child registered with an NHS dentist

Registered with dentist

Childsmile / Dental

Has the child ever attended an NHS dentist for any reason or attended over the 12 months prior to their child health review?

Ever attended dentist Attended dentist in last 12months

What was recorded in the ‘Childsmile’ box in the Future Action section of the child’s last review 
R (request assistance from) W (refused)

Childsmile outcome at last review

Does the child currently brush teeth twice daily

Child Health Systems Programme - 4-5 year review

Summary

Documentation

Coverage

Spatial

Temporal

Access and Governance

Usage

Access

Format and Standards

Origin