Accurate clinical documentation is crucial in psychiatry, particularly when diagnosing ADHD using the DSM-5 criteria. The process involves a detailed assessment of symptoms categorized under inattentive and hyperactive/impulsive types. This guide provides a step-by-step approach to correctly document these criteria, ensuring comprehensive and precise patient records.

Step 1: Inattentive Type Diagnosis

The first section of the DSM-5 ADHD criteria focuses on inattentive symptoms. This involves assessing the patient's ability to maintain attention and their organizational skills. For example, the form might include:

Inattentive Type Diagnosis Criteria:

• Displays poor listening skills: "I often have to repeat myself when talking to him."

• Loses and/or misplaces items needed to complete activities or tasks: "He frequently loses his school supplies."

• Sidetracked by external or unimportant stimuli: "He gets distracted by the smallest things."

• Forgets daily activities: "He often forgets to do his chores."

• Diminished attention span: "He can't focus on his homework for more than a few minutes."

• Lacks ability to complete schoolwork and other assignments or to follow instructions: "He rarely finishes his assignments on time."

• Avoids or is disinclined to begin homework or activities requiring concentration: "He always puts off starting his homework."

Each criterion should be carefully evaluated and documented, noting specific examples provided by caregivers or educators.

Step 2: Hyperactive/Impulsive Type Diagnosis

The second part involves assessing hyperactivity and impulsivity. Key symptoms include excessive movement and difficulty waiting turns. For example:

Hyperactive/Impulsive Type Diagnosis Criteria:

• Marked restlessness that is difficult to control: "He is always moving around."

• Appears to be driven by “a motor” or is often “on the go”: "He seems like he has endless energy."

• Lacks ability to play and engage in leisure activities in a quiet manner: "He can't play quietly."

• Overly talkative: "He talks non-stop."

• Difficulty waiting turn: "He can't wait for his turn in games."

• Interrupts or intrudes into conversations and activities of others: "He often interrupts others."

• Impulsively blurts out answers before questions completed: "He answers questions before they are finished."

Document each symptom with supporting quotations to ensure a thorough assessment.

Step 3: Additional Diagnostic Requirements and Classification

After identifying symptoms, the DSM-5 criteria require confirmation that symptoms were present before age 12 and are not better explained by another condition. The final classification determines if the ADHD is Combined Type, Predominantly Inattentive Type, or Predominantly Hyperactive/Impulsive Type.

Additional Requirements for Diagnosis:

• Symptoms present prior to age 12 years: "His symptoms started when he was around 8 years old."

• Symptoms not better accounted for by another psychiatric disorder: "No other psychiatric disorders have been diagnosed."

• Symptoms not exclusively a manifestation of oppositional behaviour: "His behaviour is not oppositional."

Classification:

• Combined Type: Patient meets both inattentive and hyperactive/impulsive criteria for the past 6 months.

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Documenting ADHD diagnoses can be cumbersome and time-consuming, but AI medical scribes like Notis can streamline this process significantly. Notis is designed to automate patient documentation by converting voice interactions into structured SOAP notes, thus enhancing efficiency in psychiatric settings.

How Notis AI Medical Scribe Enhances Psychiatry Documentation

Notis offers substantial time savings and accuracy improvements for psychiatrists. By reducing documentation time by 80%, psychiatrists can focus more on patient care rather than administrative tasks. Notis operates via WhatsApp, providing a familiar interface that requires no additional software learning, making it an accessible tool for documenting ADHD criteria.

With its multilingual support and high accuracy in voice-to-text transcription, Notis ensures that psychiatrists can maintain comprehensive and accurate patient records effortlessly. By integrating AI into psychiatric documentation, healthcare providers can improve patient outcomes and enhance the overall efficiency of their practice.