ADHD Medication Management Follow-Up Note

Date: [Date of visit]

Patient: [Patient name or identifier]

Visit Type: ADHD medication follow-up

Informants Present: [Names/roles of informants present, if any]

Visit Modality: [in-person / telehealth]

Telehealth Documentation: [Patient location (state)]; [Telehealth consent confirmed: yes / no] (Include only for telehealth visits.)

Subjective

Reason for Visit: [Brief purpose of visit] (e.g., titration follow-up, maintenance visit, refill with monitoring)

Current Regimen: [ADHD medication name(s), formulation(s), dose(s), timing, and recent changes] ([continuation / titration / restart]) (Include relevant non-ADHD medications affecting BP, HR, sleep, mood, or appetite if mentioned.)

Target Symptoms and Function: [Change in inattention, hyperactivity, impulsivity] ([better / same / worse]); [Functional impact in school/work, home routines, relationships with concrete examples] (Summarize any rating scale results or school feedback reviewed; if school feedback unavailable, document that and plan to obtain.)

Adherence: [Missed doses, timing issues, weekend drug holidays, access barriers, who manages administration] (Include only if discussed.)

Adverse Effects: [Medication-class-relevant effects: for stimulants include appetite/weight, sleep, mood/irritability, tics, cardiovascular symptoms; for atomoxetine include appetite, mood/behavior changes, and suicidality screening in youth; for alpha-2 agonists include sedation, dizziness, orthostasis, fatigue] (Document only effects reviewed for patient's current regimen.)

Safety Screening: [Misuse/diversion risk assessment for stimulants (early refills, lost meds, sharing pressure, safe storage)]; [Substance use screening when relevant]; [Interval medical history updates or new cardiac family history]

Objective

Vitals/Growth: [BP, HR, weight, height with percentiles for pediatric patients] (For telehealth, document source of vitals or state not obtained with plan. For in-person visits with missing vitals, state reason and mitigation plan.)

Exam/MSE: [Focused physical exam findings]; [Mental status exam: appearance, behavior, mood/affect, speech, thought process, attention, insight/judgment, safety assessment if indicated] (Include only elements performed.)

Data Reviewed: [Rating scales reviewed]; [School documents]; [Prescription monitoring program check]; [Other relevant data] (List only items actually reviewed today.)

Assessment

[ADHD diagnosis]; [Clinical status and medication response: optimized / improving / partial / inadequate / intolerable]; [Treatment phase: titration / maintenance]

[Comorbid conditions affecting treatment] (Include only if relevant.)

Safety/Risk Synthesis: [Vitals trend]; [Growth trajectory for pediatrics]; [Adverse effect burden]; [For stimulants: misuse/diversion risk level: low / moderate / high]

Plan

Medication Plan: [continue / increase / decrease / switch / add / hold] → [Exact regimen with medication, formulation, dose, timing]; [Rationale linked to symptom response, function, and adverse effects]; [Transition instructions if changing medications]; [Refills provided if applicable]

Monitoring Plan: [Schedule for vitals/growth checks]; [Rating scales due and from whom]; [Plan for obtaining school feedback]; [Urgent contact triggers: syncope, chest pain, severe mood changes, suicidality signs; for alpha-2 agonists include rebound hypertension risk if stopped abruptly]

Follow-up: [Timeframe based on treatment phase]; [Contingency for earlier return]

Counseling: [Medication timing and missed-dose guidance]; [Sleep hygiene]; [For stimulants: safe storage and no-sharing expectations]; [For atomoxetine in youth: warning signs discussed]; [For alpha-2 agonists: taper requirements if discontinuing] (Document topics addressed.)

(Do not infer symptom control, adherence, or absence of side effects from lack of documentation. For safety-critical missing data such as vitals when prescribing stimulants or alpha-2 agonists, include a statement indicating not obtained, the reason, and the mitigation plan. For non-critical missing information, omit the field entirely.)