ADHD Assessment Documentation: A Practical Guide for Psychologists

Documenting an ADHD assessment properly matters for diagnosis, for treatment planning, and for anyone else who reads the file later. But it's also one of the more time-consuming notes to write, with a lot of specific information to capture accurately.

Here's what a solid ADHD assessment note should include, and how to make the process faster.

What is an ADHD assessment note?

An ADHD assessment note is the clinical documentation created during (or after) a session evaluating a patient for ADHD. It captures the information needed to support a diagnosis — background history, observed and reported symptoms, mental state findings, and a clinical impression in a structured format that's useful for treatment planning and for anyone else who reads the file later.

What to include in an ADHD assessment note

Reason for Assessment Who initiated the referral and why — the presenting concerns that led to the request for an ADHD assessment.

Background History Pregnancy and birth history, developmental milestones, family structure and dynamics, family history of ADHD or other psychiatric conditions, and relevant schooling information.

Symptoms and Functional Impact The presence, frequency, and context of ADHD-related symptoms like inattention, hyperactivity, impulsivity, and how they affect functioning across social, academic, occupational, and home settings.

Observations What you observed during the session itself: attention, activity level, impulse control, ability to follow directions, and social interaction.

Mental State Examination (MSE) Behaviour, mood, affect, thought content and process, and cognitive functioning (attention, memory, concentration) observed during the clinical interview.

Behavioural Summary A synthesis of behavioural patterns across settings, consistency of reported symptoms, and any relevant psychological or developmental considerations.

Plan and Next Steps Proposed next steps further assessments, referrals, feedback sessions, psychoeducation, or recommendations for school or workplace accommodations.

Example note

All clinical examples are fictional and created for illustrative purposes only.

Reason for Assessment

• John is seeking an ADHD assessment due to persistent difficulties with attention and organisation that have impacted his work performance
• Self-referred, prompted by ongoing frustration with missed deadlines and disorganisation at work

Background History

• Normal birth and developmental milestones met on time, though behavioural issues noted in childhood
• Father was diagnosed with ADHD
• History of migraines; currently on medication for hypertension
• Struggled academically due to attention issues but received support and accommodations
• Multiple jobs held due to difficulties with task completion and organisation
• Occasional alcohol use; denies other substance use
• Previously diagnosed with anxiety and depression

Symptoms and Functional Impact

• Inattention: Often makes careless mistakes at work; struggles to maintain attention during meetings; frequently seems not to listen when spoken to directly; difficulty following complex instructions; finds it challenging to organise workload; avoids tasks requiring sustained mental effort; often misplaces important documents; easily distracted by external stimuli; forgetful in day-to-day activities
• Hyperactivity: Frequently taps his foot and fidgets; often leaves his seat during meetings; reports feeling internally restless; finds it hard to engage in quiet activities; describes feeling "driven by a motor"; talks excessively, often interrupting others
• Impulsivity: Tends to blurt out answers before questions are completed; difficulty waiting his turn in conversations; frequently interrupts others during discussions
• Symptoms cause significant impairment in occupational and social functioning

Observations

• Well-groomed but restless during the interview
• Speech rapid and occasionally tangential
• Difficulty maintaining focus on the conversation

Mental State Examination (MSE)

• Mood and affect: reported feeling frustrated; affect congruent with mood
• Thought processes: logical but occasionally disorganised
• Insight: good level of insight into his difficulties

Behavioural Summary

• 6 inattentive and 5 hyperactive-impulsive symptoms identified
• Symptoms present before age 12, consistent with childhood onset
• Symptoms not better explained by another condition
• CAARS-2 self-report: elevated scores across inattention and hyperactivity/impulsivity subscales, consistent with clinical findings

Plan and Next Steps

• Diagnostic impression: meets criteria for ADHD, combined presentation
• Discussed diagnosis and provided psychoeducation
• Recommended follow-up to discuss management options, including referral to psychiatrist for medication consultation if desired

Why this documentation takes so long

ADHD assessments are detailed by nature. You're pulling together self-report, observation, collateral information, and standardised measures into one coherent note — often across a session that ran long because the conversation genuinely needed the time.

How NirvaScribe helps

NirvaScribe listens during the session and drafts your notes as you go, organised into structured sections so the information above gets captured accurately without you typing it all out afterwards.

We also have a dedicated ADHD assessment template built in, structured around these exact sections ready to use as-is or customise to how you document.

FAQs

Does an ADHD assessment note need to include rating scale results?

Yes, it's good practice to note any standardised measures you use alongside your clinical observations. For adults, CAARS is a widely used tool in comprehensive psychologist-led assessments, often alongside the ASRS, which GPs also use as an initial screening step before referral. For children, different age-appropriate scales apply.

How long should an ADHD assessment note be?

Long enough to support your clinical reasoning there's no fixed word count. A thorough note across the sections above typically runs to one or two pages, covering background, symptoms, observations, and your plan.

Can this structure be used for both adult and child ADHD assessments?

Yes, the same core sections apply, though what you document within each will differ. For children, background history will lean more on developmental milestones and school reports; for adults, functional impact often centres on work and relationships.

If you're currently writing these notes from scratch each time, it's worth trying — start your free trial and see how much time it saves on your next assessment.

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