The document provides an example SOAP note for a 12-year-old male patient diagnosed with ADHD, detailing his symptoms, history, and assessments. It includes subjective complaints of inattention and hyperactivity along with an objective examination that shows no significant medical issues. The treatment plan involves medication, behavioral therapy, school accommodations, and parental education, with a follow-up appointment scheduled in four weeks.

1. ADHD SOAP Note Example | SOAP Note Writing
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patient with ADHD.

2. ADHD SOAP Note Example
Subjective:
• Chief Complaint (CC): "I have trouble focusing and staying on task."
• History of Present Illness (HPI): John Doe, a 12-year-old male, presents with persistent
symptoms of inattention, hyperactivity, and impulsivity. These symptoms have been present
for over a year and are impacting his academic performance and social interactions. His
parents report that he struggles to complete homework, often forgets instructions, and is
easily distracted. Teachers have noted that he fidgets frequently and has difficulty staying
seated.
• Past Medical History (PMH): No significant past medical history. No history of head trauma
or seizures.
• Family History (FH): Father has a history of ADHD. No other psychiatric conditions in the
family.
• Social History (SH): Lives with both parents and a younger sibling. Active in sports and enjoys
video games. No tobacco, alcohol, or drug use.
Review of Systems (ROS):
o General: No weight loss, fever, or fatigue.
o HEENT: No vision or hearing problems.
o Cardiovascular: No chest pain or palpitations.
o Respiratory: No shortness of breath or wheezing.
o Gastrointestinal: No abdominal pain or changes in bowel habits.
o Neurological: No headaches or seizures.
o Psychiatric: Reports difficulty focusing, hyperactivity, and impulsivity.
Objective:
• Vital Signs: BP 110/70, HR 80, RR 16, T 98.6°F, Weight 100 lbs, Height 5'0".
• General: Well-nourished, well-developed male, appears stated age, no acute distress.
• HEENT: Normocephalic, atraumatic, PERRLA, EOMI, TMs clear, no nasal discharge, throat
non-erythematous.
• Cardiovascular: S1 and S2 normal, no murmurs, rubs, or gallops.
• Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
• Abdomen: Soft, non-tender, no hepatosplenomegaly, normal bowel sounds.
• Neurological: Alert and oriented x3, normal gait, no focal deficits.
• Psychiatric: Appears restless, fidgety, makes frequent interruptions, has difficulty
maintaining attention during the interview.
Assessment:
• Diagnosis: Attention-Deficit/Hyperactivity Disorder (ADHD), combined presentation.

3. Plan:
1. Medication: Start on Methylphenidate 10 mg PO daily in the morning. Monitor for efficacy
and side effects. Schedule follow-up in 4 weeks to reassess.
2. Behavioral Therapy: Refer to a child psychologist for cognitive-behavioral therapy (CBT) to
help manage symptoms and improve coping strategies.
3. School Accommodations: Recommend meeting with school counselor to discuss possible
accommodations such as extra time on tests and a quiet environment for exams.
4. Parent Education: Provide educational materials about ADHD and discuss behavioral
management techniques. Encourage parents to establish a structured routine at home.
5. Follow-up: Return visit in 4 weeks for medication review and progress assessment.
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