ADHD Medication Initiation/Titration Note

Visit Information

Date: [Date]
Patient: [Patient name or identifier]
Age/Sex: [Age / Sex]
Visit Type: [Medication initiation / Titration follow-up / Side effect evaluation]
Informants Present: [Patient / Parent-guardian / Partner / Other]
Data Sources Reviewed: [Rating scales with informant and date / Teacher or collateral report / PDMP / Prior records] (List only those actually reviewed.)

Subjective

Chief Concern: [Patient or caregiver priority and visit purpose] (Begin with a brief quote when clinically helpful.)

Interval History: [Narrative summary including time since last dose change, current regimen with name/dose/formulation/timing/adherence, response in target settings, specific examples of benefit or ongoing impairment, and intercurrent changes] (For initiation visits, include baseline symptom narrative with 3–5 target symptoms as observable behaviors, 2–3 impairment domains, and 1–2 patient-centered goals. For titration visits, compare current status to baseline and prior dose.)

Safety and Comorbidity Screen: [Summary of psychosis/mania history or family history of bipolar disorder, baseline anxiety/depression/suicidality status, tic history, substance use history, and diversion risk factors] (At initiation, document presence or absence of each. At titration, update only if changed.)

Objective

Vitals/Growth: [Height, weight, BMI with percentiles for pediatrics, BP, HR, and weight trend since last visit] (If not obtained, document "Not obtained—[reason]" with plan to obtain. Label caregiver-reported values as "reported.")

Rating Scale Summary: (Provide a brief structured entry for each scale completed.)

• [Scale name] — [Informant and setting], [Date]: [Key scores]; [Interpretation: improved / unchanged / worse]
• (If not available: "Not available—requested from [informant] on [date]; expected by [date].")

Adverse Effect Review: [Summary of appetite/weight, sleep, mood/irritability, anxiety, somatic symptoms, tics, and cardiovascular symptoms] (Note severity only for items that are present or clinically significant. For atomoxetine, include suicidality monitoring. For alpha-2 agonists, include sedation and hypotension/bradycardia.)

Observation: [Brief clinician observations of attention, psychomotor activity, mood/affect, or concerning findings] (Omit if not clinically relevant.)

Assessment

ADHD—Medication Management: [Response status: improved / partial / none / worse] with [evidence basis: rating scale trends, collateral input, functional examples]. [Tolerability and safety status: vitals/growth, adverse effects, misuse/diversion risk]. (If data are missing, state "Response unclear—pending [specific data needed].")

Relevant Comorbidities: [Active or directly relevant conditions with brief status] (Omit section if none are active.)

Plan

Medication Decision: [Continue current dose / Increase dose / Decrease dose / Switch formulation / Switch class / Hold pending evaluation / Defer change pending data] with [explicit rationale linking to symptom response, functional change, adverse effect profile, and vitals/growth]. (If changing dose, specify new dose, timing, and guidance for managing emerging side effects.)

Diversion/Misuse Counseling (required for stimulants): [Documentation of counseling on taking only as prescribed, not sharing or selling, secure storage, safe disposal, and clinic refill policy] (At initiation, document full discussion. At titration, brief reaffirmation is sufficient.)

Monitoring Plan: [Rating scales to obtain with informants and timeline; collateral sources; vitals/growth schedule; adverse effect monitoring] (For school-age patients, include school feedback plan with what was requested, from whom, expected return date, and ROI status.)

Patient Instructions: [How and when to take medication; what to track before next visit; red-flag symptoms requiring urgent contact: chest pain, syncope, severe mood changes, psychosis, suicidality]

Follow-up: [Timing and modality] (More frequent during active titration, longer once stable. Specify what must be completed before next visit.)

(For required clinical elements—vitals, rating scales, adverse effect review—do not omit the section if data are missing. Document "Not obtained" or "Not available" with reason and plan to obtain.)