ADHD Diagnosis and Assessment Template
The Partners Pediatric Attention Deficit and Hyperactivity Disorder (ADHD) Diagnosis & Assessment Template was designed to aid in the documentation of ADHD symptoms and adherence with clinical guidelines in the assessment and management of children with ADHD. This web site includes views of each page of the template, as well as a sample clinical note.
On the Partners HealthCare System, this template exists within the notes section of the electronic medical record (EMR). In its current form, it is meant to be used by clinicians during a visit to review a patient’s ADHD symptoms and medications. The template does not provide the option of documenting other problems in detail. An advantage of this template is that it explicitly lists the DSM IV criteria for ADHD, which can be useful for primary care providers who only occasionally see such pediatric patients and therefore may have trouble remembering all of the criteria.
Note that only relevant sections of the template need be accessed during a visit. For example, if a physical examination is not performed during the visit, there is no need to access this section; it will not be included in the resulting note.
This template was developed under a grant from the Agency for Healthcare Research and Quality (AHRQ), Improving Pediatric Safety and Quality with Healthcare IT, in collaboration with the Partners HealthCare System Quality Improvement Group, the Massachusetts General Hospital for Children, and Partners HealthCare System Inc. Information Systems. Listed below are the names of clinicians and experts who contributed to development of the template. In addition, the LMR Pediatric Content Subcommittee and the main LMR Content Committee reviewed the template, and approved it for use with the Partners Longitudinal Medical Record (LMR).
Timothy Ferris, MD; MPH, Stephen Morgan, MD; Eric Poon, MD, MPH; James Perrin, MD; Shelly Bernstein, MD; Peter Greenspan, MD; John Co, MD; MPH, Mark Mandell, MD.
Template/Example Completed Clinical Note
History of Present Illness
DSM IV inattentive criteria: Poor attention to details; Listens poorly; Avoids tasks requiring substantial mental effort; Loses things; Easily distracted
DSM IV hyperactive criteria: Can't remain seated; Runs or climbs inappropriately
DSM IV impulsive criteria: Can't wait his/her turn
General: Symptoms present before age 7?; Impairment in two or more settings?
Source of Information
Parent or guardian; Classroom teacher
Basis for Diagnosis of ADHD
History of symptoms meeting DSM-IV criteria: Yes
ADHD DSM-IV based rating scale: Vanderbillt/NICHQ
Conduct Disorder: No
Anxiety Disorder: No
Obsessive Compulsive Disorder: No
Progress Since Last Visit
School Performance: Maintained
Parent Satisfaction: Worsened
Goals Set: use positive reinforcement at home
Counseled in behavior modification techniques; Counseled about expected benefits and possible adverse effects; Counseled about medication misuse
Duration of Counseling: 15 minutes
Side effects: None
Follow-up visit: 6 months
These tools were created using national, state, and local guidelines, and group consensus regarding best practices. These guidelines, and their interpretation by clinicians at Partners Healthcare System, may not represent the standard of care across all regions or settings, and are not intended to be adopted or applied without independent assessment of their suitability for a particular setting. Moreover, guidelines change over time (for example, the age range for children who should receive influenza vaccinations was recently extended to 59 months). The rules and/or reminders contained within these templates may need the addition or modification of certain items to ensure that they remain consistent with current guidelines. Therefore, the tools included here are intended only as examples or guides for the development of similar templates in other settings. Partners Healthcare System and its affiliates disclaim any and all responsibility or liability associated with the use of the templates displayed here by third parties.