Pediatric Documentation Templates

ADHD Diagnosis & Assessment Template

Executive Summary

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.

Source

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).

Contributors

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 Existing Problem

Symptoms

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

Depression     No

Obsessive Compulsive Disorder No

Progress Since Last Visit

School Performance Maintained

Parent Satisfaction Worsened

Goals Set: use positive reinforcement at home

Treatment Plan

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

Disclaimer

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.