13 min read

ADHD SOAP Note Example: Documentation for Adults & Children

Dr. Medeline Yost

Chief Medical Officer, Augustun

Published July 11, 2026

Updated July 11, 2026

On this page

What Makes ADHD Documentation Different
Adult vs Pediatric ADHD Documentation
Rating Scales for ADHD Notes
Fillable ADHD SOAP Note Template
ADHD SOAP Note Examples
Stimulant vs Non-Stimulant Documentation Tips
Common ADHD SOAP Note Mistakes
ICD-10 Codes Commonly Used in ADHD Notes
Let an AI Scribe Draft Your ADHD Notes
Conclusion
FAQ

ADHD documentation looks simple until an auditor asks where the functional impairment lives, why you chose a stimulant, and how you ruled out anxiety or sleep debt as the real driver of inattention. A strong ADHD SOAP note answers those questions in every visit — not only at diagnosis.

Adult and pediatric ADHD notes share the same SOAP spine, but the evidence base is different: workplace deadlines and ASRS scores on one side of the desk; parent and teacher Vanderbilt reports and growth curves on the other. Stimulant follow-ups add another layer — blood pressure, heart rate, appetite, sleep, and careful language around misuse risk — that general psychiatry templates often bury.

This guide sits beside our psychiatric SOAP note hub and the broader how to write psychiatry notes walkthrough. Below you will find what makes ADHD charting different, adult vs pediatric tables, rating-scale guidance, a fillable template, and four complete ADHD SOAP note examples you can adapt today.

What Makes ADHD Documentation Different

ADHD is a neurodevelopmental diagnosis defined by persistent patterns of inattention and/or hyperactivity-impulsivity that impair function across settings. Your note has to show that pattern — not a single bad week after a late night — and connect symptoms to concrete losses at work, school, home, or relationships.

Three documentation domains carry most of the clinical weight:

Attention domain — sustained focus, distractibility, forgetfulness, task initiation, organization, time blindness, and careless errors, with examples tied to real tasks.
Hyperactivity / impulsivity domain — restlessness, fidgeting, interrupting, impulsive spending or decisions, and difficulty waiting; adults often present as internal restlessness rather than overt motor hyperactivity.
Functional impact — missed deadlines, incomplete projects, academic underperformance relative to ability, driving citations, relationship strain, and compensatory strategies that are no longer enough.

Medication visits add a fourth requirement: stimulant and non-stimulant monitoring. Appetite, sleep, blood pressure, heart rate, weight (especially in children), and any concerning use pattern belong in Objective or Plan every time you renew a controlled substance. Vague phrases like 'doing fine on Adderall' will not support medical necessity or controlled-substance due diligence.

Cross-setting evidence

DSM-5-TR requires symptoms in two or more settings. For children, document parent and teacher (or other caregiver) input. For adults, document work or academic performance plus home/relationship function — and childhood onset whenever you can reconstruct it from history or collateral.

Medical necessity language should connect the dots explicitly: which ADHD symptoms persist, how they impair role function, what non-medication strategies have been tried, and why the current pharmacologic plan is indicated. That sentence or two in Assessment or Plan is often what separates a clean stimulant renewal from a payer query.

Adult vs Pediatric ADHD Documentation

Same SOAP structure; different informants, scales, and safety checks. Use this table as a quick checklist when switching between age groups.

Element	Adult ADHD	Pediatric ADHD
Primary informants	Patient; partner or employer when available	Parent/guardian plus teacher or school counselor
Core scales	ASRS-v1.1 (screener + symptom checklist); optional WURS for childhood recall	Vanderbilt (parent and teacher); SNAP-IV; Conners when used in your clinic
Functional focus	Work output, academic persistence, driving, household management, relationships	Classroom behavior, homework completion, peer interactions, grades vs ability
Onset documentation	Retrospective childhood symptoms before age 12 when possible	Current developmental history; onset often already evident in school years
Med monitoring emphasis	BP, HR, sleep, appetite, mood irritability, misuse/diversion screen	BP, HR, weight/height trajectory, appetite, sleep, rebound, school timing of dose
Common differentials	Anxiety, depression, sleep apnea, substance use, bipolar hypomania	Learning disorders, anxiety, ODD, sleep problems, trauma, vision/hearing issues

Rating Scales for ADHD Notes

Scales do not replace clinical judgment, but they make severity and change visible across visits. Record the instrument name, version, raw or subscale scores, and a one-line interpretation tied to function.

Scale	Population	What to document
ASRS-v1.1	Adults	Part A screener positives; full symptom checklist if used; compare to prior visit
Vanderbilt ADHD Diagnostic Rating Scale	Children (parent & teacher forms)	Inattention and hyperactive/impulsive symptom counts; performance items; comorbidity screens
SNAP-IV	Children / adolescents	ADHD and ODD item averages; useful for treatment-response tracking

When anxiety coexists, add GAD-7 (adults) or a pediatric anxiety screen so the Assessment can separate ADHD inattention from worry-driven distraction. For the anxiety-specific SOAP pattern, see our anxiety SOAP note example.

Score trends matter more than a single snapshot. Write both the number and the clinical meaning: 'ASRS Part A improved from 6/6 positives at initiation to 4/6 at month three, consistent with better meeting attendance but residual task-initiation delay.' That phrasing shows response without claiming remission you have not earned.

Fillable ADHD SOAP Note Template

Copy this skeleton into your EHR template library. Trim sections that do not apply; never leave stimulant monitoring blank on a renewal visit.

ADHD SOAP Note — Template

S (Subjective): Chief complaint in patient/parent words. Attention and hyperactivity/impulsivity symptoms since last visit (or onset for new eval): frequency, settings, severity. Functional impact at work/school/home with concrete examples and direct quotes. Sleep, appetite, mood, anxiety, substance use. Medication adherence, timing, perceived benefit, and side effects. Pediatric: parent report + teacher/school feedback. Adult: childhood symptom history when relevant. Safety: SI/HI screen; for stimulants, any lost/stolen scripts, early refill requests, or sharing of medication.
O (Objective): Appearance, behavior (restlessness, fidgeting, distractibility in session), speech, mood/affect, thought process/content, perception, cognition/attention in interview, insight/judgment. Vitals: BP, HR; weight (± height/BMI in pediatrics). Rating scales: ASRS, Vanderbilt (parent/teacher), SNAP-IV, plus PHQ-9/GAD-7 if used. Pediatric growth parameters when on stimulants.
A (Assessment): ADHD diagnosis with presentation (predominantly inattentive / hyperactive-impulsive / combined) and ICD-10 code (e.g., F90.0, F90.1, F90.2). DSM-5-TR criteria met; settings affected; severity and change since last visit. Differentials considered (anxiety, mood, sleep, learning disorder, substance). Comorbid diagnoses. Risk formulation including SI/HI. For controlled substances: clinical rationale for continued prescribing and monitoring plan.
P (Plan): Medication: continue / adjust / start / stop with dose, timing, and rationale. Non-pharmacologic: CBT for ADHD, coaching, school accommodations (504/IEP), organizational strategies. Monitoring: next BP/HR/weight, labs if indicated, PDMP check per local requirements. Patient/parent education on side effects, storage, and not sharing medication. Follow-up interval and what will be reassessed (symptoms, scales, function, vitals).

ADHD SOAP Note Examples

Names and details are illustrative. Adapt the structure; keep the functional and monitoring specificity.

Example 1 — Adult Stimulant Follow-Up

Jordan is a 34-year-old software engineer on a stable methylphenidate regimen returning for a 3-month med check. Focus on appetite, sleep, BP/HR, work function, and controlled-substance diligence.

ADHD SOAP Note — Adult Stimulant Follow-Up

S (Subjective): 34-year-old with ADHD, combined presentation, returns for stimulant follow-up. Continues methylphenidate ER 36 mg qAM. Reports: 'I can finally get through standup without losing the thread, and I closed two projects on time this month.' Still forgets secondary tasks unless written down. Appetite mildly suppressed at lunch; dinner intake normal; weight stable by home scale. Sleep 7 hours; no mid-afternoon crash. Denies irritability, chest pain, or palpitations. Takes medication as prescribed; denies lost/stolen scripts, early refill requests, or sharing medication. Occasional caffeine (1 coffee). Denies alcohol binge or illicit stimulant use. Denies SI/HI.
O (Objective): Well-groomed, sits still with occasional foot tapping. Speech normal rate. Mood 'pretty good'; affect full and congruent. Thought process linear; no psychosis. Attention adequate for 25-minute interview; briefly distracted by phone notification then refocused. Insight good; judgment intact. ASRS symptom checklist: 4/6 Part A items still positive but improved from 6/6 at initiation; inattentive items milder. Vitals: BP 124/78 (prior 122/76), HR 76 (prior 74). Weight 172 lb (stable). PDMP reviewed — fills consistent with prescribed interval.
A (Assessment): 1) ADHD, combined presentation (F90.2) — partial-to-good response to methylphenidate ER 36 mg; functional gains at work with residual organizational deficits. 2) No current depressive or anxiety disorder meeting criteria. Stimulant monitoring: BP/HR within acceptable range vs baseline; appetite effect mild and non-limiting; no red flags for misuse. Suicide risk: denies ideation — low acute risk. Medical necessity supported by persistent ADHD symptoms with documented occupational impairment improved on current regimen.
P (Plan): Continue methylphenidate ER 36 mg qAM. Reinforced protein-forward breakfast and lunch scheduling given mild appetite suppression. Externalizing strategies (task list, calendar blocks) reviewed. Educated on secure storage and not sharing medication. Next visit in 3 months with repeat ASRS, BP/HR, weight; sooner if insomnia, marked appetite loss, mood change, or cardiovascular symptoms. E-prescribed 90-day supply with no early refill per clinic controlled-substance policy.

Example 2 — Adult New Evaluation / Medication Start

Priya is a 28-year-old graduate student presenting for first psychiatric evaluation of longstanding inattention. The note must establish childhood onset, cross-setting impairment, differentials, and rationale for starting a stimulant.

ADHD SOAP Note — Adult New Evaluation

S (Subjective): 28-year-old female self-refers for 'lifelong focus problems that finally blew up in my master's program.' Reports chronic difficulty sustaining attention in lectures, losing keys/phone weekly, starting assignments late despite high motivation, and reading the same paragraph repeatedly. Hyperactivity denied now; childhood teacher comments noted 'daydreamer' and 'needs to try harder.' Symptoms present before age 12 per patient and mother (phone collateral). Impairs school (incomplete drafts, two extensions this semester) and home (unpaid bills until overdue). Sleep 6.5–7 hours; screens for OSA negative (no snoring/witnessed apneas). Anxiety present as secondary worry about deadlines, not free-floating worry most days. Denies manic episodes, psychosis, and current substance use other than rare alcohol. No prior ADHD diagnosis; never tried prescription stimulants. Denies SI/HI. Goals: finish thesis on schedule and reduce late fees/missed appointments.
O (Objective): Casually dressed, appropriate grooming. Mild restlessness (shifts posture, clicks pen). Speech normal. Mood 'frustrated with myself'; affect congruent, reactive. Thought process goal-directed. No perceptual disturbance. Oriented x3; digit span mildly reduced; loses track once when interrupted then recovers. Insight good; judgment intact. ASRS-v1.1 Part A: 5/6 items positive. PHQ-9 = 6; GAD-7 = 8. Vitals: BP 118/72, HR 68. Weight 132 lb. Cardiac ROS negative; no personal/family sudden cardiac death. Urine toxicology discussed; patient agreeable if required before stimulant start per clinic policy.
A (Assessment): 1) ADHD, predominantly inattentive presentation (F90.0) — meets DSM-5-TR criteria with childhood onset, persistent inattentive symptoms, and clear impairment in academic and home settings; ASRS screener positive. 2) Mild anxiety symptoms secondary to academic stress — does not fully account for lifelong inattention. R/O learning disorder contribution — refer for academic assessment if thesis deficits persist after ADHD treatment. R/O primary insomnia/OSA — low suspicion. No bipolar spectrum red flags. Suicide risk low. Benefit of trial stimulant outweighs risks after shared decision-making; baseline vitals reassuring.
P (Plan): Start lisdexamfetamine 30 mg qAM after food; discuss expected onset, appetite/sleep effects, and emergency symptoms (chest pain, syncope, severe agitation). Secure storage counseling; written agreement regarding no sharing, no dose escalation without contact, and refill timing. CBT skills handout for planning/prioritization; encourage university disability services for temporary accommodations. Follow-up in 3–4 weeks for response, side effects, BP/HR, weight, and repeat ASRS items. Mother invited to send childhood school comments if available. Crisis resources provided.

Example 3 — Pediatric Med Check with Parent and Teacher Report

Marcus is an 9-year-old returning with his mother for an amphetamine salt follow-up. Teacher Vanderbilt data and growth parameters are essential Objective content.

ADHD SOAP Note — Pediatric Med Check

S (Subjective): 9-year-old male with ADHD, combined presentation, accompanied by mother for 2-month follow-up. Continues mixed amphetamine salts ER 15 mg qAM on school days; weekends held per prior plan. Mother: 'Mornings are smoother — he gets dressed without a fight, and homework takes 40 minutes instead of two hours.' Afternoon irritability ('rebound') from ~3:30–5:00 pm on school days, milder than last visit. Appetite down at school lunch; dinner good; no skipped meals at home. Sleeps 9.5 hours; no insomnia. Teacher email summary (mother brought printout): fewer call-outs, still incomplete independent seatwork when instructions are multi-step. Child states: 'Medicine helps my brain stay on the paper.' Denies headaches, stomach pain lasting >1 day, tics, or sadness. No known sharing/diversion (parent stores and administers). Denies SI/HI (age-appropriate screen).
O (Objective): Active but redirectable in office; makes intermittent eye contact; no aggression. Speech normal. Mood 'good'; affect bright. Thought content age-appropriate; no psychosis. Attention: needs one redirect during history. Parent Vanderbilt: inattentive symptoms 5/9 (was 8/9); hyperactive/impulsive 4/9 (was 7/9); performance items improved in written expression and classroom behavior. Teacher Vanderbilt (returned this week): inattentive 6/9; hyperactive/impulsive 3/9; notes incomplete work on multi-step tasks. Vitals: BP 108/68, HR 82. Height 134 cm (55th %ile), weight 29.8 kg (48th %ile) — previously 30.4 kg two months ago (−0.6 kg); growth chart reviewed with parent.
A (Assessment): ADHD, combined presentation (F90.2), improving on mixed amphetamine salts ER 15 mg with residual inattention per teacher report and afternoon rebound. Mild weight deceleration since last visit — monitor closely; not yet meeting threshold to stop stimulant if nutrition strategies succeed. No evidence of mood disorder, tics, or significant anxiety. Low acute safety risk. Cross-setting data (parent + teacher) support continued treatment with dose/timing reconsideration for rebound and seatwork completion.
P (Plan): Continue mixed amphetamine salts ER 15 mg qAM school days. Add structured afternoon snack at 3:00 pm and brief movement break to address rebound; if rebound persists at next visit, discuss small immediate-release booster vs schedule adjustment. Nutrition counseling: high-calorie breakfast before dose, pack preferred lunch items. Parent to request teacher update in 4 weeks on multi-step task completion; consider school 504 check-in for chunked instructions. Recheck weight/height, BP, HR in 4 weeks (earlier if appetite worsens). Medication locked at home; parent-only administration reinforced. Return precautions for chest pain, fainting, marked mood change, or tics.

Example 4 — ADHD with Comorbid Anxiety

Elena is a 41-year-old with established ADHD whose residual 'focus' complaints overlap with escalating GAD. The Assessment must untangle which symptoms belong to which diagnosis — and the Plan should treat both without blaming one medication for all remaining deficits.

ADHD SOAP Note — ADHD + Comorbid Anxiety

S (Subjective): 41-year-old with ADHD (inattentive) and GAD returns for combined med management. On atomoxetine 80 mg daily x4 months and sertraline 75 mg daily x8 weeks. Reports: 'Adderall used to quiet the static, but the worry is what's loud now — I reread emails because I'm scared I sounded wrong, not because I didn't see the words.' Task initiation still delayed on low-interest work; less forgetfulness of appointments since atomoxetine. New: muscle tension, initial insomnia (45–60 min), and catastrophizing about a performance review. Caffeine 2 cups; alcohol 2–3 drinks/week. Denies panic attacks, mania, and SI/HI. Prefers to avoid restarting a stimulant while anxiety is high; open to sertraline optimization and ADHD coaching skills.
O (Objective): Tense posture, intermittent hand wringing; no gross hyperactivity. Speech slightly rapid when discussing work evaluation. Mood 'wired and worried'; affect anxious, reactive, tearful once then recovers. Thought process linear; content notable for anticipatory worry, no obsessions meeting OCD threshold, no psychosis. Concentration fair — self-corrects when anxious narrative derails topic. Insight good; judgment intact. ASRS residual inattentive items moderate. GAD-7 = 14 (was 11 eight weeks ago). PHQ-9 = 7. Vitals: BP 126/80, HR 78. Weight stable.
A (Assessment): 1) ADHD, predominantly inattentive (F90.0) — partial response to atomoxetine with improved prospective memory; residual initiation/organization deficits. 2) Generalized Anxiety Disorder (F41.1) — currently primary driver of 'focus' complaints via worry loops and insomnia; GAD-7 worsened despite sertraline 75 mg. Differentiating feature documented: error-checking driven by fear of negative evaluation rather than primary attentional lapse. No stimulant misuse history; shared decision to defer stimulant re-trial until anxiety improves. Suicide risk low.
P (Plan): Increase sertraline from 75 mg to 100 mg daily for incomplete GAD response; continue atomoxetine 80 mg daily. Sleep hygiene and scheduled 'worry window' before bed. Referral to CBT for ADHD + anxiety (cognitive restructuring + externalizing systems). Hold stimulant restart for now; revisit if inattention remains impairing after anxiety improves. Follow-up in 3 weeks with GAD-7, ASRS items, sleep log, BP/HR. Provided psychoeducation distinguishing ADHD inattention from anxiety-driven distraction. Crisis line resources reviewed.

Stimulant vs Non-Stimulant Documentation Tips

Both medication classes treat ADHD; the note's monitoring language should match the pharmacology and the regulatory reality of controlled substances.

Stimulants (methylphenidate, amphetamine salts, lisdexamfetamine)

Document BP and HR at baseline and each renewal; note comparison to prior values, not only 'vitals stable.'
Track weight (and pediatric height/growth percentiles). Comment on appetite strategies when suppression is present.
Ask about sleep, rebound, irritability, tics, and cardiac symptoms; document negatives that matter.
Address misuse and diversion risk carefully: record adherence pattern, PDMP review when applicable, lost-script history, and education on secure storage — without pejorative labels. Prefer 'no early refill requests; PDMP consistent with prescribed interval' over speculative character judgments.
State the clinical rationale for continued controlled-substance prescribing tied to function and scale trends.

Non-stimulants (atomoxetine, viloxazine, guanfacine, clonidine, bupropion off-label)

Document time to benefit (often weeks) so partial early response is not misread as failure.
For atomoxetine/viloxazine: mood, appetite, liver-symptom ROS as indicated; BP/HR still relevant.
For alpha-agonists: sedation, BP/HR, rebound hypertension risk if abruptly stopped — counsel and document.
Explain why a non-stimulant was chosen (anxiety comorbidity, substance-use history, patient preference, prior stimulant intolerance) so the Assessment supports the Plan.

For broader med-management structure beyond ADHD, see our psychiatric medication management note guide.

Common ADHD SOAP Note Mistakes

Documenting symptoms without function

'Patient reports poor focus' does not establish impairment. Tie attention or impulsivity to missed deadlines, grade drops, driving incidents, or relationship consequences.

Skipping collateral or second-setting data

Pediatric notes without teacher input — and adult notes that never address work or home — leave a DSM gap. Even a brief teacher Vanderbilt or partner collateral belongs in the record.

Renewing stimulants without monitoring

A Plan that only says 'refill Adderall 90 days' without BP/HR, weight, side-effect review, and adherence/PDMP language is a compliance and safety gap.

Collapsing anxiety into ADHD

If worry, insomnia, and fear of evaluation are driving 'distraction,' say so in Assessment. Treating only ADHD while GAD escalates produces confusing scale trends and frustrated patients.

Pejorative misuse language

Document observable behaviors and policy-relevant facts. Avoid unsupported labels. Clear, neutral monitoring language protects patients and clinicians.

Omitting childhood onset in adult evaluations

Adult ADHD still requires a neurodevelopmental timeline. If childhood data are unavailable, document what you asked, what the patient recalled, and any collateral — and note residual diagnostic uncertainty rather than inventing a neat childhood history.

ICD-10 Codes Commonly Used in ADHD Notes

Match the code to the presentation you actually documented. Specifiers in Assessment should agree with the ICD-10 selection.

F90.0 — ADHD, predominantly inattentive presentation
F90.1 — ADHD, predominantly hyperactive-impulsive presentation
F90.2 — ADHD, combined presentation
F90.8 / F90.9 — other or unspecified ADHD (use sparingly; prefer a specific presentation when criteria are clear)

List comorbid codes (e.g., F41.1 for GAD) when they independently drive treatment decisions. Do not bury anxiety inside F90.x if you are titrating an SSRI primarily for worry.

Let an AI Scribe Draft Your ADHD Notes

ADHD visits move quickly — rating scales, parent-teacher updates, vitals, and controlled-substance counseling all compete with the clinical conversation. Augustun for psychiatry listens during the encounter and drafts a structured SOAP note that captures symptom domains, functional impact, and medication monitoring details so you can stay present with the patient (or family) in the room.

Augustun supports SOAP and other behavioral-health formats, suggests ICD-10 codes, and pushes finished notes into 400+ EHRs through a browser extension. It is built for clinical use with HIPAA compliance, and recordings are never stored. You review, edit, and sign.

Built for behavioral health

From adult stimulant follow-ups to pediatric Vanderbilt reviews, Augustun adapts to psychiatry workflows. Comparing tools? See our roundup of the best AI scribe for psychiatry, or explore Augustun for psychiatry.

Conclusion

A strong ADHD SOAP note shows the symptom domains, proves functional impairment across settings, tracks rating scales over time, and documents medication safety with the same rigor you bring to diagnosis. Adult notes lean on ASRS and occupational impact; pediatric notes need parent and teacher data plus growth monitoring; comorbid anxiety deserves its own Assessment — not a footnote.

Start from the template, borrow structure from the four examples, and keep stimulant monitoring non-negotiable on every renewal. Clear ADHD documentation supports better treatment decisions, smoother audits, and continuity when another clinician picks up the chart.

Frequently asked questions

What should an ADHD SOAP note include?

Capture attention and hyperactivity/impulsivity symptoms with functional examples, mental status and vitals (BP, HR, weight), rating-scale scores (ASRS, Vanderbilt, or SNAP-IV), an Assessment with ADHD presentation and ICD-10 code plus differentials, and a Plan covering medication rationale, monitoring, behavioral strategies, and follow-up. Pediatric notes should include parent and teacher input.

How do you document a stimulant medication check?

Record adherence and perceived benefit, appetite, sleep, mood/irritability, BP and HR versus baseline, weight (and pediatric growth), any cardiac symptoms, and controlled-substance diligence (PDMP when used, lost scripts, education on storage and not sharing). Tie continued prescribing to ongoing impairment and treatment response.

Which rating scales belong in ADHD documentation?

Adults commonly use the ASRS-v1.1. Children typically use parent and teacher Vanderbilt forms; SNAP-IV is also used for symptom tracking. Document the instrument name, scores, and a brief interpretation. Add PHQ-9 or GAD-7 when mood or anxiety may confound attention complaints.

How is pediatric ADHD documentation different from adult notes?

Pediatric notes rely on parent and teacher collateral, school function, and growth parameters on stimulants. Adult notes emphasize work or academic performance, retrospective childhood onset, and often ASRS scores. Both require cross-setting impairment and medication monitoring appropriate to the regimen.

Can an AI scribe write ADHD SOAP notes?

Yes. An ambient AI scribe like Augustun can draft structured ADHD SOAP notes from the visit conversation — including symptom domains, scales mentioned, vitals, and plan details — for you to review and sign. See Augustun for psychiatry and our best AI scribe for psychiatry guide for workflow fit.