Accurate clinical documentation is essential in psychological assessments, particularly when diagnosing ADHD. This guide will walk you through writing and formatting ADHD assessment notes, focusing on essential sections such as Mental Status Examination (MSE), Observations, and patient history. Let's explore how a psychologist can structure these notes effectively.

Mental Status Examination (MSE)

The MSE is a critical component in documenting a patient's current mental state. It involves describing the patient's behavior, mood, thoughts, and cognition. For example:

• Behavior: Document observations such as "The patient appeared restless and frequently shifted in their seat during the session."

• Mood: Record both the patient's self-reported mood and the psychologist's observations, e.g., "The patient reported feeling frustrated and overwhelmed. The psychologist observed signs of irritability."

• Thoughts: Note coherence and orientation, such as "The patient's thoughts were coherent and oriented to time and place."

• Cognition: Mention any concerns or lack thereof, for instance, "No concerns reported or observed."

Observations

In this section, include any notable behaviors during the assessment that may impact diagnosis. For example, "The patient frequently tapped their foot and seemed distracted by noises outside the room." These detailed observations provide context for understanding the patient's condition.

Reason for Assessment

Clearly state why the patient was referred for evaluation, e.g., "The patient was referred for an ADHD assessment due to ongoing difficulties with attention and impulsivity impacting their academic performance."

Background Information

Comprehensive background information is crucial. Include details such as family dynamics and medical history. For instance:

• Family Members: "Lives with both parents and a younger sibling."

• Family History: "The patient's father has a history of ADHD."

• School and Year Level: "Attends Greenfield High School, currently in Year 9."

• Pregnancy and Birth History: "No significant concerns reported."

• Childhood History: "Experienced frequent ear infections as a child."

Symptoms of Inattention and Hyperactivity/Impulsivity

List specific symptoms observed or reported, aligned with diagnostic criteria. For example:

• Inattention: "The patient often makes careless mistakes in math assignments."

• Hyperactivity and Impulsivity: "The patient frequently taps their foot during class."

Conclude this section by discussing how these symptoms interfere with the patient's functioning across different settings, such as social, academic, or home environments.

AI medical scribes like Notis AI Medical Scribe can revolutionize the documentation process for psychologists. By automating note-taking, they significantly reduce the time spent on administrative tasks, allowing clinicians to focus more on patient care.

Benefits of Using Notis AI Medical Scribe

Notis offers several advantages in documenting ADHD assessments:

• Time Efficiency: By cutting down patient documentation time by 80%, psychologists can save up to 2 hours per day.

• Ease of Use: Integration with WhatsApp ensures a seamless transition with no need for additional software.

• High Accuracy: With a 99% accuracy rate in transcribing medical notes, it ensures precise documentation.

• Comprehensive Documentation: Notis structures notes in the SOAP format, which is ideal for clinical settings.

For psychologists, leveraging AI tools like Notis can enhance productivity and accuracy in documenting patient interactions, ultimately improving the quality of care provided.